Lecture 30: AIDS and Headache

Question 1

Is meningitis a concern in a patient with a headache for ten days?

Answer 1

Yes, it could potentially be chronic meningitis. Although this would be atypical.

Question 2

What are some possible causes of prolonged headaches in a patient with HIV?

Answer 2

• Brain abscess due to toxoplasma gondii

- Cryptococcus neoformans, a cause of meningitis in immunocompromised patiuents.

Question 3

What are common causes of dysphagia in AIDS patients?

Answer 3

Candida albicans colonies in the throat and pharynx

Question 4

What are two very common AIDS diagnoses?

Answer 4

• Candida albicans oesophagitis

- Cryptococcus neoformans meningitis

Question 5

Relate AIDs diagnoses in relation to declining CD4 count:

Answer 5

CD4 decline

Early stage diagnosis: Tuberculosis, herpes, oral candidiasis

Middle stage diagnosis: Pneumocystis pneumonia, oesophogeal candidiasis

Later stage: Toxoplasm, crytptococcal meningitis, kaposis sarcoma

Last stage: CMV disease, MAIC disease

Question 6

What are other causes of lymphopenia (similar to AIDS):

Answer 6

• Immunosuppression to prevent rejection of an organ transplant
• Chemo of lymphatic malignancy

Question 7

What are the two fungal disease in AIDS?

Answer 7

Oral and oesophogeal mucosal disease due to candida albicans

Meningitis due to cryptococcus neoformans (gradual onset, chronic)

Question 8

How can fungal infections be divided?

Answer 8

Common, minor, skin and mucosal infections

and

Rare, serious, deep tissue infections

Question 9

What is the excessively simple classification of fungi:

Answer 9

Divided into:

Yeasts

Moulds

Question 10

Write some notes on yeasts:

Answer 10

• Round or oval, reproduce by budding
• Candida albicans and other candida
• Cryptococcus neoformans

Question 11

Write some notes on moulds:

Answer 11

• Tubular hyphae, reproduce by spores
• Dermatophytes
• Aspergillus species

Question 12

Write some notes on candida albicans:

Answer 12

Commensal of mouth, gut, vagina.

Overgrowth related to antibacterial therapy, immune suppression, hormonal effects, foreign bodies

Causes:

• Oral or vaginal ‘thrush’
• Cutaneous or nail candidiasis
• Urinary catheter bladder infections
• Rare systemic infection

Question 13

Describe the diagnosis of candida albican:

Answer 13

It is seen as black yeasts with psuedo-hypae on gram stain

It grows well on blood agar

Question 14

Describe the treatment of candidiasis:

Answer 14

Usually topical, sometimes oral.

• Nystatin suspension or pastilles
• Amphotericin B pastilles
• Azole pessaries or cream

Azoles commonly

Question 15

Describe how C. Neoformans causes disease:

Answer 15

Pulmonary infection

• Due to inhalation of fungus from environment
• Totally controlled in people with normal immune
• Usually asymptomatic

Spread via blood to CSF
- Only in people with severe immunodeficiency

Meningitis in immunodeficient people
- i.e AIDS, high dose prolonged corticosteroids therapy etc

Chronic lymphocytic meningitis
- Slow deterioration in mental state with head ache and fever

Question 16

How is cryptococcus meningitis diagnosed?

Answer 16

Usually: 10-100 WBCs in CSF lymphocyte not PMN predominance protein raised, glucose low

Encapsulated yeasts seen with india ink stain. C. Neoformans grown on agar

Cryptococcal antigen +ive in CSF and serum

Question 17

Whats the treatment for cryptococcal meningitis?

Answer 17

IV amphotericin B
IV or Oral Fluconazole

Approx six weeks total therapy

Question 18

What are some dermtophytes?

Answer 18

Tinea, capitis etc

Question 19

What are the treatments for dermatophytes?

Answer 19

For skin: A topical azole
i.e clotrimazole, econazole etc

For nails: An oral agents
i.e Terbinafine for 3-4 months or itraconazole for 3-4 months

Question 20

Whats the mould/infection of deeper tissues?

Answer 20

Aspergillus fumigatus

• Spore bearing branching mould in rotting vegetation
• Rare cause of disease in neutropenic patients, can also cause allergic bronchopulmonary aspergillosis

Question 21

What are the concerns of amphotericin B:

Answer 21

Risk of infusion related anaphylaxis, neprohtoxicity with K loss.

Disrupts cytoplasmic membrane

Question 22

What are the causes of fever and headache and impaired thinking?

Answer 22

Meningitis (All microbes)
Brain abscess (Bacteria)
Encephalitis (Virus)

Question 23

Whats the risk of examining the CSF?

Answer 23

Do CT/MRI before lumbar puncture to prevent pressure drop/brain shift due to pressure gradient.