Three major forms:

ORAL

1. pseudomembranous thrush - most common/ white mucosal plaques

2. erythematous - painful erythema

3. angular chelitis - mildy painful, ulcerated

Esophageal Candidiasis - dysphagia or odynophagia

vaginal candidiasis - pruritis/mild pain with white mucosal plaques

can confirm with KOH or culture

Treatment: oral imadazoles (fluconazole) or topical therapy (nystatin or clotrimazole)

for pseudomembranous thrush - treat with fluconazole

most common infectious AIDS defining Dx, when CD4 is less than 200 or <14%

caused by pneumocystitis jiroveci, and PCP is usually due to reactivation, rarely new

Clinical: Progressive, non-productive cough, dyspnea, fever, fatigue; subacute onset in HIV, slowly progresses

Exam: tachypnea, often clear lung at rest

CXR: reveals diffuse interstitial infiltrates but may be "normal" early

etiologic diagnosis is based on specimen obtained at BAL or bronchial biopsy/GIemsa and methenamine silver stains

Treatment: trimethoprim/sulfamethoxazole - 21 days

a CNS manifestation of AIDS

- Cryptococcus neoformans - encapsulated yeast

- most frequently causes meningitis but disseminated disease (lung, skin, and bone marrow)

- occurs in about 8% of HIV patients

- CD4 is usually less than 100

symptoms: subacute onset of headache, fever, confusion, and vomiting

exam: usually non-focal

MRI/CT: variable, normal, meningeal enhancement or edema, rare cryptococoma

Dx: India ink stain cryptococal ag in CSF

Rx: Induction: Amphotericin B +/- flycytosine for two weeks, or high dose fluconazole

primary cause of death: failure to recognize increased CSF pressure, which may require CNS shunt

caused by toxoplasma gondii, disease usually due to reactivation of tissue cysts (brain, muscle, and heart), CD4 count is usually less than 100

symptoms: focal encephalitis resulting in headache, confusion, focal neuro deficits (motor weakness), seizures, and occasional fever, this is unlike cryptococcus

classic presentation: usually reveals several ring-enhancing lesions with edema
Rx: sulfadiazine 4-6 gms/d +pryrimethamine 200 mgd initially/ Clindamycin if sulfa allergic

parasite found in water supply; infection due to ingestion of oocytes

occurs in 2-3% of HIV patients

may occur at any CD4 count-acute or subacute onset

Sx: large volume (liters/day) watery diarrhea, bloating, crampy pain, blood/pus rare

Dx: modified afb on stool/ IFA or EIA

Rx: Nitazoxanide 500 mg BID for 14 days

decreased visual acuity

retinitis is most commmon sign of CMV infection AIDS through disseminated disease, GI, pulmonary, or CNS disease can occur

CD4<50, in 10% of patients

signs: fundoscopic exam reeals full thickness necrotizing retinitis with fluffy yellow-white lesions, intraretinal hemorrhage with little vitreous inflammation; vascular sheathing; late-retinal detachment, no eye redness, tearing or swelling

diagnosis: supported by +CMV blood and urine cultures or PCR

Treatment: Ganiclovir or Vitrasert implant and oral valganciclovir

drug toxicities: cytopenia with ganciclovir; renal/electrolyte problems with foscarnet

MAC - occurs in up to 25% of patients

CD4<40 with dissemination, Fever, night sweats, abdominal pain, diarrhea, fatigue, and weight loss usually subacute onset

Lab: anemia

Management requires multidrug therapy: ethambutol, clarithromycin, cipro, amikacin (rifabutin), chronic rx is required!

primary prophylais for CD4<50 cells: Azithromycin or Clarithromycin; Rifabutin is alternative for prophylaxis but drug interactions are common

multicentric tumor caused by HHV8, may occur at any CD4 count in HIV

Rx: chemotherapy, interferon, and radiation

first type of lymphoma recognized as HIV related, most due to EBV

DX: CSF PCR for EBV or cytopathology or brain biopsy

Rx: usually radiation