Поширені прояви ВІЛ-інфекції за системою органів
Syndrome | Cause | Diagnostic Evaluation | Treatment* | Symptoms/Comments |
|---|---|---|---|---|
Cardiac | ||||
Direct viral damage to cardiac myocytes | Echocardiography | Antiretroviral drugs | Symptoms of heart failure | |
Gastrointestinal | ||||
Candidiasis, CMV, or herpes simplex virus | Esophagoscopy with biopsy of ulcers | Treatment of cause with antiviral and antimicrobial drugs | Dysphagia, anorexia | |
Gastroenteritis or colitis | Intestinal Salmonella, MAC, Cryptosporidium (cryptosporidiosis), Cyclospora (cyclosporiasis), CMV, microsporidia, Cystoisospora (Isospora) belli (cystoisosporiasis), or Clostridioides difficile | Cultures and stains of stools or biopsy, but determination of cause possibly difficult | Treatment of cause:
| Diarrhea, weight loss, abdominal cramping |
CMV, Cryptosporidium, Cyclospora, or microsporidia | Ultrasonography or endoscopy | Antimicrobial drugs for Cryptosporidium, Cyclospora, and microsporidia | Possibly pain or obstruction | |
Rectal and perirectal lesions | Proctitis caused by Neisseria gonorrhoeae or Chlamydia trachomatis (particularly LGV), HSV, syphilis | Examination Gram staining and culture Nucleic acid amplification testing (NAAT) RPR/treponemal antibody test Biopsy | Treatment of cause | High incidence in women and men who have sex with men via anal receptive sexual intercourse† |
Hepatocellular damage due to hepatitis viruses, opportunistic infections, or antiviral drug toxicity | TB, MAC, CMV, or peliosis (bartonellosis), chronic hepatitis B or chronic hepatitis C, which may be worsened by HIV | Differentiation from hepatitis due to antiretroviral or other drugs Liver biopsy sometimes necessary | Treatment of cause | Symptoms of hepatitis (eg, anorexia, nausea, vomiting, jaundice) |
Genital/Reproductive Tract | ||||
Anal and external genital lesions | Herpes simplex virus (HSV) Genital warts or anal or cervical cancer induced by HPV | Examination Gram staining and culture Nucleic acid amplification testing (NAAT) Biopsy | Treatment of cause | High incidence in women and men who have sex with men via anal receptive sexual intercourse† |
Pelvic inflammatory disease | Neisseria gonorrhoeae, Chlamydia trachomatis, or other usual pathogens | Possibly increased in severity, atypical presentation, and more difficult to treat in women with HIV | ||
Vaginal candidiasis | Candida spp. | Possibly increased in severity or recurrence in women with HIV | ||
Hematologic | ||||
Anemia | Multifactorial: HIV-induced bone marrow suppression Immune-mediated peripheral destruction Anemia of chronic disease Infections, particularly human parvovirus B-19, disseminated MAC, or histoplasmosis Cancers | For parvovirus B19 infection, bone marrow examination (to check for multinucleated erythroblasts) or serum or bone marrow PCR | Treatment of cause Transfusion as needed Erythropoietin for anemia due to antineoplastic drugs or zidovudine if severity warrants transfusion and erythropoietin level is < 500 mU/L IVIG for parvovirus | With parvovirus, sometimes acute severe anemia |
Immune thrombocytopenia, drug toxicity, HIV-induced bone marrow suppression, immune-mediated peripheral destruction, infections, or cancer | CBC, clotting tests, PTT, peripheral smear, bone marrow biopsy, or von Willebrand factor measurement | Antiretroviral drugs IVIG for bleeding or preoperatively Possibly anti-Rho (D) IgG, vincristine, danazol, or interferon If severe and intractable, splenectomy | Often asymptomatic and may occur in otherwise asymptomatic HIV infection | |
HIV-induced bone marrow suppression, immune-mediated peripheral destruction, infections, cancer, or drug toxicity | For severe neutropenia (< 500/mcL) plus fever, immediate broad-spectrum antibiotics If drug-induced, granulocyte or granulocyte-macrophage colony-stimulating factors | — | ||
Neurologic | ||||
Mild to severe cognitive impairment with or without motor deficits | Direct virus-induced brain damage | HIV RNA level in CSF CT or MRI to check for brain atrophy (nonspecific) | Antiretroviral drugs, which may reverse damage and improve function, although low levels of cognitive dysfunction commonly persist, even in treated patients | Progression to dementia uncommon in treated patients |
Ascending paralysis | Guillain-Barré syndrome or CMV polyradiculopathy | Spinal cord MRI CSF testing | Treatment of CMV polyradiculopathy Supportive care for Guillain-Barré syndrome | Neutrophilic pleocytosis in patients with CMV polyradiculopathy, possibly simulating bacterial meningitis |
Acute or subacute focal encephalitis | Toxoplasma gondii (toxoplasmosis) | CT or MRI to check for ring-enhancing lesions, especially in basal ganglia Antibody testing of CSF (sensitive but not specific) PCR testing to check for T. gondii DNA in CSF Brain biopsy (rarely indicated) | Pyrimethamine, folinic acid, sulfadiazine, and possibly sulfamethoxazole/trimethoprim, SMX-TMP, Cotrimoxazole (clindamycin if allergic to sulfa—see Toxoplasmosis: Treatment of patients with AIDS or other immunocompromising conditions) Often lifelong maintenance therapy | Primary prophylaxis with clindamycin and pyrimethamine or sulfamethoxazole/trimethoprim, SMX-TMP, Cotrimoxazole (as for Pneumocystis pneumonia) indicated for patients with a CD4 count of < 100/mcL and previous toxoplasmosis or positive antibodies; can be stopped if CD4 counts increase to > 200/mcL for ≥ 3 months in response to antiretroviral therapy |
Subacute encephalitis | Less often, herpes simplex virus or varicella-zoster virus | CSF PCR Response to treatment | Antiviral drugs | With CMV, often delirium, cranial nerve palsies, myoclonus, seizures, and progressively impaired consciousness at presentation Often responds rapidly to treatment |
Myelitis or polyradiculopathy | CMV | Spinal cord MRI CSF PCR | Antiviral drugs | Simulates Guillain-Barré syndrome |
Progressive encephalitis of white matter only | Progressive multifocal leukoencephalopathy due to reactivation of latent JC virus infection HIV | Brain MRI CSF testing | Antiretroviral drugs to reverse the immunodeficiency (no drugs are effective for JC virus) | Usually fatal within a few months May respond to antiretroviral drugs |
Coccidioidomycosis, Cryptococcus (cryptococcosis), Histoplasma (histoplasmosis), or Mycobacterium tuberculosis | CT or MRI CSF stains, antigen tests, PCR, and cultures | Treatment of cause | Outcomes improved by early treatment | |
Direct effects of HIV or CMV or antiviral drug toxicity | History Sensory and motor testing | Treatment of cause or withdrawal of toxic drugs | Very common Not quickly reversible | |
Ophthalmologic | ||||
Retinitis | CMV or VZV | Direct retinoscopy | Specific anti-CMV or anti-VZV drugs | Requires examination by specialist VZV causes acute retinal necrosis in some patients with end-stage HIV |
Oral | ||||
Oral candidiasis | Immunosuppression by HIV | Examination | Systemic antifungals | Possibly painless in early stages |
Mpox (formerly monkeypox) virus | Examination PCR of fluid from vesicles | Antiviral drugs | Painful, vesicular rash can begin in mouth then spread High incidence in men who have sex with men† | |
Intraoral ulcers | Herpes simplex virus or aphthous stomatitis | For aphthous ulcers, intralesional or systemic corticosteroids and systemic montelukast and thalidomide For herpes, acyclovir | May be severe and result in undernutrition | |
Mixed oral bacterial flora | Examination | Improved hygiene and nutrition Antibiotics | May be severe, with bleeding, swelling, and tooth loss | |
Painless intraoral mass | Kaposi sarcoma, lymphoma, or tumors induced by HPV | Biopsy | Treatment of neoplasm | — |
Painless white filiform patches on the sides of the tongue (oral hairy leukoplakia) | Examination | Acyclovir | Usually asymptomatic | |
Pulmonary | ||||
Subacute (occasionally acute) pneumonia | Mycobacteria Fungi such as P. jirovecii, C. neoformans, H. capsulatum, Coccidioides immitis, or Aspergillosis | Pulse oximetry Chest x-ray Skin tests (sometimes false-negative because of anergy) Bronchoscopy with special stains and cultures of bronchial lavage specimens sometimes necessary | Treatment of cause | Possibly cough, tachypnea, and chest discomfort at presentation Mild hypoxia or increased alveolar-arterial oxygen gradient possibly occurring before evidence of pneumonia on x-ray |
Acute (occasionally subacute) pneumonia | Typical bacterial pathogens or Haemophilus, Pseudomonas, Nocardia, or Rhodococcus | In patients with known or suspected HIV and pneumonia, exclusion of opportunistic or unusual pathogens | Treatment of cause | Possibly cough, tachypnea, and chest discomfort at presentation |
Tracheobronchitis | Candida spp. or herpes simplex virus (HSV) | — | Treatment of cause | Possibly cough, tachypnea, and chest discomfort at presentation |
Subacute or chronic pneumonia or mediastinal adenopathy | Kaposi sarcoma or B-cell lymphoma | Chest CT Bronchoscopy | Treatment of cause | Possibly cough, tachypnea, and chest discomfort at presentation |
Renal | ||||
Nephrotic syndrome or renal insufficiency | Direct viral damage, resulting in focal glomerulosclerosis | Renal biopsy | Antiretroviral drugs or ACE inhibitors possibly useful | Increased incidence in African Americans and patients with a low CD4 count |
Tubular dysfunction (glucosuria, proteinuria) | Some antiviral drugs | Urinalysis and/or blood tests | Dose reduction or discontinuation of the antiviral drug | — |
Skin | ||||
Varicella-zoster virus (VZV) | PCR-based testing DNA testing on scrapings from vesicular skin lesions that have not yet crusted Culture (best if done on unroofed and recently ruptured vesicles) | Acyclovir or related drugs | Common Possible prodrome of mild to severe pain or tingling before skin lesions PCR-based testing is most sensitive | |
Herpes simplex ulcers | PCR-based testing of ulcer HSV culture of ulcer | Antiviral drugs if lesions are severe, extensive, persistent, or disseminated | Atypical lesions of herpes simplex are extensive, severe, or persistent PCR-based testing is most sensitive | |
Sarcoptes scabiei | Clinical evaluation and scrapings | Possibly severe hyperkeratotic lesions | ||
Vesicular painful rash | Examination PCR of fluid from vesicles, pustules, and/or dry crusts | Antiviral drugs | Rash can spread Lymphadenopathy is common | |
Violaceous or red papules or nodules | Kaposi sarcoma or bartonellosis | Biopsy | Antiretroviral drugs and treatment of cause | — |
Centrally umbilicated skin lesions | Cryptococcosis or molluscum contagiosum | See Molluscum contagiosum: Diagnosis and Cryptococcosis: Diagnosis | May be the presenting sign of cryptococcemia | |
Systemic | ||||
Sepsis and septic shock due to nosocomial gram-negative bacillary and staphylococcal infections, disseminated opportunistic infections | Gram-negative bacilli, Staphylococcus aureus, Candida spp., Salmonella, M. tuberculosis, MAC, or H. capsulatum | Blood cultures Bone marrow examination | Treatment of cause | — |
Wasting syndrome (substantial weight loss) | Multifactorial, including AIDS, AIDS-related opportunistic infections, AIDS-related cancers, and/or AIDS-induced hypogonadism | Defined as weight loss of > 10% of body weight | Antiretroviral drugs (the primary treatment for this syndrome) Treatment of underlying infections; treatment of AIDS-induced hypogonadism when indicated Measures to improve appetite and caloric intake | — |
CBC = complete blood count; CMV = cytomegalovirus; CSF = cerebrospinal fluid; HPV = human papillomavirus; HSV = herpes simplex virus; IVIG = IV immune globulin; MAC = Mycobacterium avium complex; Mpox = monkeypox; PCR = polymerase chain reaction; PTT = partial thromboplastin time; TMP/SMX = trimethoprim/sulfamethoxazole/; TB = tuberculosis; VZV =varicella-zoster virus | ||||
* Antiretroviral drugs are always part of the treatment plan. They are listed in this treatment section only when there is no more specific treatment. † These diagnoses are surrogates of behaviors that increase the risk of HIV infection; when present, these diagnoses should prompt HIV testing. | ||||