Aids B24.x2

Author: Prof. Dr. med. Peter Altmeyer

Last updated on: 13.03.2021

Synonym(s)

Acquired immune deficiency syndrome; Acquired Immune Deficiency Syndrome; AIDS full picture; immune deficiency syndrome acquired

Definition
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Stage 1-4 (CDC 1993) of HIV infection, characterised by the occurrence of opportunistic infections or AIDS-defining tumours.

Etiopathogenesis
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Infection with HIV (Human Immunodeficiency Virus).

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Clinical features
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AIDS-related complex, opportunistic infections and tumours (see table).

Therapy
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Antiretroviral therapy as a combination regime under control of viral load and CD4 cell progression (see below HIV infection). Adequate therapy of opportunistic infections and HIV-associated tumours (see table below) as well as for the corresponding clinical pictures, introduction of primary prophylaxis against opportunistic infections, see below. HIV infection. After some opportunistic infections, secondary prophylaxis until the immune system is restored (> 300 CD4-T lymphocytes) is necessary (see table).

Tables
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Major AIDS-defining opportunistic infections and tumours

	Pathogen / Cause	Opportunistic infection or tumour
Protozoa	Toxoplasma gondii	Cerebral or disseminated toxoplasmosis
	Cryptosporidium parvum	chronic intestinal cryptosporidiosis
	Isospora belli	chronic intestinal isosporidiosis

Fungi	Pneumocystis carinii	Pneumocystis carinii pneumonia
	Candida spp.	Candida esophagitis, bronchitis, tracheitis or pneumonia
	Cryptococcus neoformans	extrapulmonary cryptococcosis
	Histoplasma capsulatum	disseminated or extrapulmonary histoplasmosis

Viruses	herpes simplex	chronic herpes simplex ulcers or bronchitis, pneumonia, esophagitis
	Cytomegalovirus	CMV retinitis, generalized CMV infection (not of liver or spleen)
	Jakob Creutzfeld virus	progressive multifocal leukoencephalopathy
	HIV virus	HIV encephalopathy, wasting syndrome

Bacteria	Salmonella spp.	rec. Salmonella septicaemia
	Mycobacterium tuberculosis	Tuberculosis of any localization
	M. avium intracellulare	Non-tuberculous mycobacterioses of any localization

Tumours		Kaposi's sarcoma
		malignant lymphomas (e.g. Burkitt's lymphoma, primary cerebral lymphoma)
		invasive cervical carcinoma

Note: In Thailand, Talaromyces marneffei infection is the third most common AIDS-defining disease after tuberculosis and cryptococcosis.

Therapy of non-dermatological opportunistic infections and tumours in AIDS patients

Disease	Clinic	Diagnostics	Therapy
Pneumocystis carinii pneumonia	Dry cough, fever, progressive dyspnoea on exertion, weight loss, decrease in performance.	Auscultation usually o.k.; hypoxemia, LDH-, BSG ↑.	Cotrimoxazole (e.g. Eusaprim forte) 4 times 1920 mg/day p.o. for 3 weeks.
		Chest x-ray: interstitial proliferation of drawings, especially in the middle and lower fields.
			Alternative: Pentamidine inhalations (e.g. pentacarinate) 200 mg for 4 days or Atoquavon (Wellvone) 3 times 750 mg/day p.o. for 3 weeks.
		Histology, PCR (provoked sputum, BAL, transbronchial biopsy).

Cerebral toxoplasmosis	Subacute onset of mono- or hemiparesis, sensory disturbances, visual field defects, decrease in vigilance, change in character, headache, fever, epileptic seizures.	CT or NMR: One or more space-occupying lesions with annular or patchy KM uptake and perifocal edema. Pathogen detection by PCR.	Pyrimethamine (Daraprim) day 1 200 mg, then 100 mg/day p.o. plus sulfadiazine (e.g., Sulfadiazin-Heyl) 3-4 times 2 g/day p.o. for 4-6 weeks.
			Alternative: Atovaquone (Wellvone) 4 times 750 mg/day p.o.

Candida esophagitis	Dysphagia, tenesmus, diarrhea, weight loss, retrosternal pain.	Candida detection.	Fluconazole (Diflucan) 400 mg/day p.o. for 2-3 weeks.
			Alternative: itraconazole (Sempera) 100-200 mg/day p.o. 2 times.

CMV retinitis	Restricted visual field, threat of blindness.	Characteristic ocular fundus changes	Foscarnet (foscavir) initially 2 times 90 mg/kg bw/day i.v. in 500 ml NaCl 0.9% for 2-3 weeks; maintenance therapy: 90 mg/kg bw i.v. 5 days/week for life.
			Alternative: Ganciclovir (Cymeven) 2 times 5 mg/kg bw/day i.v. for 3 weeks, then maintenance therapy with 6 mg/kg bw i.v. 5 days/week.
			Alternative: Intravitreal injections or implantation of a drug depot (pellets) by specialized ophthalmologists.

Secondary prophylaxis of opportunistic infections in AIDS

Disease	Substance	Dosage	Preparation
Pneumocystis carinii pneumonia	Cotrimoxazole	480 mg/day p.o. or 960 mg 3 times/week	Eusaprim forte
Pneumocystis carinii pneumonia	Dapsone	100 mg 2 times/week p.o.	Dapson-Fatol
Toxoplasmosis	Cotrimoxazole	480 mg/day p.o.	Eusaprim forte
	Alternative: Pyrimethamine	50-75 mg/day p.o.	Daraprim
	Alternative: Folinic acid	5 mg/day p.o.	Lederfolate
Systemic candidiasis	Fluconazole	50 mg/day p.o. or 3 times 100 mg/week	Diflucan
Systemic candidiasis	Alternative: Itraconazole	100 mg/day p.o.	Sempera
Aspergillosis	Itraconazole	400-600 mg/day p.o.	Sempera
Aspergillosis	Alternative: Amphotericin B	0.75 mg/kg bw i.v. 2-3 times/week	amphotericin B
Cryptococcosis	Fluconazole	200 mg/day p.o.	Diflucan
Cryptococcosis	Alternative: Itraconazole	400 mg/day p.o.	Sempera
Histoplasmosis	Itraconazole	200-400 mg/day p.o.	Sempera
Histoplasmosis	Alternative: Fluconazole	200-400 mg/day p.o.	Diflucan
Atypical mycobacteriosis	Rifabutin	300 mg/day p.o.	Mycobutin
	Alternative: Azithromycin + Rifabutin	1200 mg/week p.o. + 300 mg/week p.o.	Ultreon + mycobutin
	Alternative: Clarithromycin	2 times 500 mg/day p.o.	Klacid, Mavid
Herpes zoster	Aciclovir	2 times 400-800 mg/day p.o.	Aciclovir
CMV retinitis	Ganciclovir (alternating with Foscarnet)	5-6 mg/kg bw 5 times/week i.v.	Cymeven
CMV retinitis	Foscarnet	90-120 mg 5 times/week i.v.	Foscavir

Literature
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Hamouda O (2003) HIV/AIDS surveillance in Germany. J Acquir Immune Defic Syndr 32: S49-54
Kelly JA et al (2003) The newest epidemic: a review of HIV/AIDS in Central and Eastern Europe. Int J STD AIDS 14: 361-371
Knodela J et al. The impact of the AIDS epidemic on older persons. AIDS 16: S77-83
Letvin NL et al (2003) Immunopathogenesis and immunotherapy in AIDS virus infections. Nat Med 9: 861-866
Sabin CA (2002) The changing clinical epidemiology of AIDS in the highly active antiretroviral therapy era. AIDS 16: S61-68
Scadden DT (2003) AIDS-related malignancies. Annu Rev Med 54: 285-303
Weiss RA (2003) HIV and AIDS: looking ahead. Nat Med 9: 887-891