HIV Disease: Opportunistic Infx's and Co-Morbidities Flashcards
Complications of HIV
2:
- Opportunistic Infxs
- Co-morbs
Comps of HIV Disease
Opportunistic Infxs vs Co-morbidities
Whats the main difference?
You will see Opportunistic Infxs in pts w/ HIV who are NOT successfully tx’d w/ ART
Comps of HIV Disease
Opportunistic Infxs
Seen in people w/ suppressed immune systems such as pts w/ HIV who are NOT successfully treated w/ ART
Comps of HIV Disease
Co-morbs
Seen in SOME HIV+ people→ EVEN those who ARE successfully treated w/ ART***
Opportunistic Infxs come from
Well…one contributor..
LOW CD4 counts
HOW can a person who is HIV+ avoid getting an opportunistic infx?
- Take ART EVERY DAY (prn/prescribed)
-
Goal:
- NON-detectable lvls
- Maint CD4 count so immune system can function
Opportunistic Infections
Kaposi’s Sarcoma
- Skin, mucous membranes
-
MAY affect lymphatic system
- Lymphedema
- Painful LEs
Opportunistic Infections
Pneumocystis carinii pneumonia (PCP)
Think “Fungal” one*
Also….”Pneumo”→ LUNGS!
- Up to 85% of healthy adults possess antibodies
- Fever, dyspnea, hypoxia
These are ESP. in Compromised immune systems
2:
TB
Non-Hodgkin’s Lymphoma
Opportunistic Infections
Oral thrush (Candidiasis)
*Fungal also!!
Opportunistic Infections
Mycobacterium** Avium (MAC)**
INITIALLY affect GI and Pulmonary tracts
Opportunistic Infections
Tuberculosis (TB)
- RE-surgence in NON-HIV pops in poor urban areas**
- Up to ⅓ HIV+ individuals coinfected w/ Myobacterium TB
- 23% deaths due to TB***
Opportunistic Infections
Non-Hodgkin’s Lymphoma
Know it exists as an opportunistic infx
along w/ TB→ ESPECIALLY in compromised immune systems
This tumor is RARE in NON-HIV population
Cerebral Lymphoma
Neuro comps of HIV:
Caused by 4:
-
Specific tumors:
-
Cerebral lymphoma
- NOTE: this is RARE in NON-HIV pop.
-
Cerebral lymphoma
- Opportunistic infxs
- PRIMARY HIV infx
- Autoimmune rxns*
Neuro comps of HIV
Can include:
- Peripheral neuropathies* (COMMON)
- Cog impairs
- SZs
- Dementia
- Para/Hemiplegia
- Other focal deficits→ depending upon location of patho.
Opportunistic CNS Infxs
Explain how we get them there…
- Blood/brain barrier (BBB) usually prevents entry of infectious material
-
HIV is able to cross BBB**
- maybe on its own, maybe in infected macrophages and T-cells
- Even in a normal immune system→ LESS immune protection in CNS vs rest of body:
- NO lymphatic system
- LOWER antibody lvls
- FEWER WBCs
Even in a normal immune system→ LESS immune protection in CNS vs rest of body:
3 reasons WHY?
- NO lymphatic system
- LOWER antibody lvls
- FEWER WBCs
CNS Opportunistic Infx
Meningitis
In general…
- Inflammation of meninges of the brain and/or SC
- *USUALLY a complication of another infx
-
Sx’s:
- HA, nausea, painful stiff neck, altered LOC
- Usually extends into cortex and SC
- Potentially severe comps
CNS Opportunistic Infx
Meningitis
Cryptococcal Meningitis
-
MOST COMMON FUNGAL INFX IN THE CNS***
- ~5% of people w/ AIDS
- Infx usually limited to meninges→ Sxs similar to meningitis
MOST COMMON FUNGAL INFX IN THE CNS
~5% of people w/ AIDS
Cryptococcal Meningitis
This CNS Opportunistic Infx often Co-Exists w/ Meningitis
Encephalitis
CNS Opportunistic Infx
Encephalitis
- Gen inflammation of Parenchyma
- Cause MAY be Viral
- Herpes simplex, Herpes Zoster, Cytomegalovirus (CMV)
- Cause MAY be Viral
-
Findings:
- Aphasia, SZs, hemiparesis, s/s intracranial mass, fever, HA
- *Similar to, but distinct from, Meningitis
- **OFTEN COEXIST!
CNS Opportunistic Infx
Brain Abscess
- Due to local infx, OR spread from distant infx
- INC incidence w/ exotic protozoan OR fungal organisms
- Abscessed area becomes→ Necrotic and encapsulated
-
Sx risk:
- Exposes CNS structures to other antigens
Medical Tx for Brain Abscess
-
Antibiotics→ MUST cross BBB to be effective
- Intrathecal tx often used BUT:
- Neurotoxic SEs
- Drug conc LOW in Lat. ventricles
- Intrathecal tx often used BUT:
- Incision and drainage
CNS Opportunistic Infx
Cerebral Toxoplasmosis
ALL STUFF
-
Cause→ reactivation of dormant toxoplasma cysts (T. gondii protozoan)
- Oocysts excreted by cats; eggs survive in soil (litter) for extd pds of time
-
*MOST COMMON INTRACRANIAL infx in PWAIDS
- 80-90% w/ CD4 count <100*
-
Deficits→ Focal
- SZ, hemiparesis, ataxia, aphasia, HA, mental status change, confusion, lethargy
MOST COMMON INTRACRANIAL INFX in PWAIDS
Cerebral Toxoplasmosis
Cerebral Toxoplasmosis
MOST common intracranial infx in PWAIDS
Potentially curable?
POTENTIALLY curable w/ EARLY Tx
*Relapses common (in compromised immune systems)
Cerebral Toxoplasmosis
MOST common intracranial infx in PWAIDS
PREVENTION for PW HIV:
- Gloves working in garden
- Avoid raw/undercooked meat
- Wash hands after handling raw meat/veggies
- Avoid changing litter box (if cats) or use gloves/mask
This DEmyelinating disease (Opportunistic Infx) is RARE
Progressive Multifocal Leukoencephalopathy (PML)
CNS Opportunistic Infx
Progressive Multifocal Leukoencephalopathy (PML)
-
Demyelinating dis.
- Cause→ papoVIRUS→ Present, BUT dormant in brain most people
-
RARE!→ <1% OF PWAIDS
- SEVERE neuro sx’s may lead to death
Cytomegalovirus (CMV)
Think…. “OPTIC”!!!
- Primarily Optic structures
- CAN affect GI and respiratory systems
Comorbs/Complications can be seen in _________ treated w/ ________
Long term survivors; treated w/ ART
MSK Complications are mostly found _________ in disease process
LATE
MSK Complications a frequently a ________ of ________ resulting in _____________
2* complication of neurologic deficits resulting in improper mechanics of mvmt and compensatory strategeis
MSK Complications
How and leads to what?
2* complication of neuro deficits resulting in improper mechanics of mvmt and compensatory strategies
When are MSK complications found ?
LATE in disease process
SC patho specific to people w/ AIDS
Vacuolar Myelopathy
COMORBIDITIES
Vacuolar Myelopathy
- SC patho specific to PWAIDS
- Due to→ macrophages in lateral and post. columns of SC
-
Sx’s:
- weakness, spasticity, ataxia, sensory changes, reflex changes (Hoffman’s)
- Later→ urinary/fecal incont, dementia
- weakness, spasticity, ataxia, sensory changes, reflex changes (Hoffman’s)
- *Variable progression over time
COMORBIDITIES
MOST COMMON NEUROLOGICAL COMPLICATION OF AIDS***
AIDS DEMENTIA COMPLEX
COMORBIDITIES
AIDS DEMENTIA COMPLEX
MOST COMMON NEUROLOGIC COMPLICATION OF AIDS***
COMORBIDITIES
Neuro complication→ AIDS Dementia Complex
*MOST COMMON NEURO COMPLICATION OF AIDS
- Thought to be due to HIV infx in brain
- Progressive cog loss w/ motor and behavioral dysf.
-
Early signs:
- Apathy, social w/draw, depression, Diff concentration and complex mental tasks
MOST COMMON COMPLICATION of HIV Disease (NOTE just “complication”)
Peripheral Neuropathy
COMORBIDITIES
Peripheral Neuropathy
Most common complication of HIV Disease
COMORBIDITIES
Peripheral Neuropathy
*most common comp. of HIV dis.
3 types:
- Distal Sensory Polyneuropathy (DSP)→ MOST COMMON*
- Stocking-glove numbness, parasthesia, burning
- Demyelinating Polyneuropathy
- Mononeuropathy
What should you remember about Peripheral Neuropathy?
DISTAL MUSCLES!!!!
Peripheral Neuropathy: Issues for PT
-
DISTAL WEAKNESS in advanced cases; weakness in foot mm’s (intrinsic and extrinsic)
- PROnation, Tendinitis
- Grip weakness, balance/sensory/proprio deficits
- Gait disturbs, mvmt disorders
- PAIN!!!!
Kietrys Study Example DSP
see pics
Another Kietrys Study Example DSP
see pics
What is Myopathy ?
Inflammatory disease of mm tissue
COMORBIDITIES
HIV Associated Myopathy
Primarily WHERE?
PROXIMAL MUSCLES!!!
Trunk, shoulder girdles, pelvic girdles
DSP vs HIV ASSOCIATED MYOPATHY
DSP→ Distal mm’s (just remember DSP, Distal..both start w/ D!!)
HIV Associated Myopathy→ Proximal mm’s
COMORBIDITIES
HIV Associated Myopathy
What etiology suspected?
Autoimmune etiology
HIV Associated Myopathy
*Proximal mm’s!
- Progressive, symmetric, PAINLESS, weakness of Proximal limb mm’s+trunk
- Biopsy→ muscle fiber necrosis
- Autoimmune etiology suspected*
W/ Myopathy…
Appropriate interventions?
GENTLE ROM & stretching as tolerated ONLY!
COMORBIDITIES
Myopathy
- Inflammatory dis. of muscle
- Etiology→ MAY be related to zidovudine (AZT) and chronic dis. process
- Sx’s→ PROXIMAL weakness, diffuse aching, “myalgia”
- Dx→ serial CPK lvls (leaks as mm destroyed), EMG, mm biopsy
COMORBIDITIES
Acute, inflammatory Myopathy
- ELEVATING serial CPK lvls
COMORBIDITIES
Chronic Myopathy
CPK lvls DECLINING toward NORMAL
*NOTE: when steroids kick in
Acute, inflamm myopathy vs Chronic myopathy
ACUTE→ ELEVATING CPK lvls
CHRONIC→ CPK lvls DECLINE TOWARDS NORMAL
Acute, inflammatory Myopathy
PT + Medical Mx:
-
PT→
- AVOID strenuous activity, OK to do gentle ROM and stretching as tolerated
-
Med Mx→
- anti-inflamms and analgesics
- *nutritional support
Chronic Myopathy
PT:
-
PT→
- SLOWLY progress to PREs w/ emphasis on proximal musculature***
COMORBIDITIES
This is the one w/ the Truncal obesity********
Lipodystrophy
COMORBIDITIES
Lipodystrophy
The “truncal obesity” one***
- Truncal obesity→ INCd subQ and visceral fat
- enlarged dorsocervical fat pad (whale hump)
- atrophy and fat wasting in extremities and face (remember the calves, sunken face!!!)
- *Insulin resistance
COMORBIDITIES
Lipodystrophy Diagnosis:
Observation, bioimpedance abnorms, abnorm blood lipids (HypERlipidemia, HypERglycemia), body comp changes, metabolic changes
COMORBIDITIES
Lipodystrophy Etiology:
UNCLEAR: related to prolonged use of antiviral meds (PIs, NNRTIs), OR chronic dis. process
COMORBIDITIES
Lipodystrophy Interventions:
Aerobic exercise and PREs, growth hormones, testosterone, anabolic steroids, nutrition support
Dealing w/ Body Composition Changes
(HIV Related Muscle Wasting)
Egrifta
Egrifta= precursor to HGH
See study pics/results
Long term survivors of HIV aka People Living w/ HIV (PLHIV)
this is common
Chronic pain
Chronic Pain in PLHIV
-
Prev→ 39-55%
- HIGHER + higher severity of pain in indigent population
- Concurrent psychiatric illness→ 40% more likely pain
- Concurrent subs abuse→ higher pain severity and disruption daily function
Multifactorial Etiology of Chronic Pain in PLHIV:
- Direct effects of HIV infx
- Chronic inflamm and immune activation
- SEs of ART drugs/other drugs
- Neuro mechs
- Comorbs/Multimorbs
- Opportunistic infx’s***
- Aging/frailty
- Psychosocial influences
- Rx opiods misuse/heroin use
- Gender/ethnic diffs→ perception/expression of pain
2 MOST COMMON CHRONIC PAIN AREAS
+ A 3rd and example
- *SPINAL
- *ARTHRALGIA (Jt pain)
- Neuropathic (Peripheral neuropathy)