Journal of the Association of Physicians of India
JAPI
Editor : Dr. Siddharth N. Shah
Journal of the Association of Physicians of India
JAPI
Editor : Dr. Siddharth N. Shah
Current Issue • July 2018 • Vol. 66
Original Article
Incidence and Spectrum of Opportunistic Infections Among HIV Infected Patients Attending Government Medical College, Kozhikode
PK Vinod1, Chandni Radhakrishnan2*, Sasidharan PK3
1
Junior Resident, 2
Additional Professor, 3
Formerly Professor and Head of Medcine, Government Medical College, Kozhikode,
Kerala; *
Corresponding Author
Received: 01.09.16; Accepted: 02.04.2018
Abstract
Background: People with advanced human immunodeficiency virus (HIV ) infections are vulnerable to opportunistic infections because of a weakened immune system. Early diagnosis of Opportunistic infections and prompt treatment definitely contributes to increased life expectancy among infected patients and delays the progression to AIDS.
Aims and Objectives: are to study the incidence, clinical spectrum and outcome of opportunistic infections and relation between opportunistic infections and CD4 count.
Material and Methods: The study was carried out in the Anti Retroviral Treatment (ART ) clinic and medical wards of Government Medical College, Kozhikode. The study period was from January 2012 to January 2013 till 100 opportunistic infections are identified in newly diagnosed retro positive patients. This was a clinical observational study. 424 newly diagnosed retro positive patients were screened to identify 100 patients having opportunistic infections and they were studied in detail.
Results: Out of the 100 patients, 71 were males and 29 were females.67% were in the age group of 30-49 years. The most common symptom of presentation was weight loss (77%) followed by fever (67%) and mucocutaneous lesions (60%). The commonest opportunistic infection detected was candidiasis (52%) followed by tuberculosis (50%).Majority of the patients had a CD4 count between 50-200/ microL. Out of the 100 patients 19 patients expired. Among them 10 patients had disseminated tuberculosis. Incidence of opportunistic infection was 23.59/100 person years.
Conclusions: This study demonstrates that Oral candidiasis is the commonest
opportunistic infection in HIV patients and Tuberculosis is the second most
common. The incidence of opportunistic infection is higher in the older age
groups, males and patients with lowCD4 count.
Introduction
People with advanced HIV infections
are vulnerable to opportunistic
infections (OI) because of a weakened
immune system. OI cause substantial
morbidity and mortality. The common
OI that affecting people living with
HIV infection in India are Tuberculosis,
Candidiasis, Pneumocystis jiroveci
pneumonia (PCP), Bacterial pneumonia,
Herpes simplex, Herpes zoster and
chronic diarrhea.
Early diagnosis of OI and prompt
treatment definitely contributes to
increased life expectancy among
infected patients and delays the
p r o g r e s s i o n t o A I D S ( A c q u i r e d
immunodeficiency syndrome) and
it also helps to stop the spread of
Tuberculosis and other transmissible
OI.1,2 The relative frequencies of specific
OI may vary in different countries
and even in different areas within the
same country. The pattern of OI in HIV patients in south Indian context
is relatively less studied. This study
was done to estimate the burden of
OI and its pattern in HIV patients in
North Kerala.
Materials and Methods
This is a clinical observational
study carried out in the Anti retro viral
treatment (ART) clinic and medical
wards of Government Medical College,
Kozhikode. The study was done after
getting institutional ethics committee
approval and informed consent from
the patients. The study period was
from January 2012 to January 2013
till 100 subjects with OI are enrolled.
All patients above 12 yrs of age who
found to be HIV positive after testing
from ICTC (Integrated counseling and
testing centre) during the study period
were included in the study. Patients
who were already had other immune
compromised state before contracting
HIV like diabetes mellitus and patients
on chemotherapy were excluded from
the study.
424 newly diagnosed consecutive
retro positive patients were clinically
assessed to identify 100 patients who
had opportunistic infections and
they were studied in detail. Data
collected by thorough history taking,
m e t i c u l o u s c l i n i c a l e x a m i n a t i o n
a n d r e l e va n t i n ve s t i g a t i o n s . A l l
the investigations were routinely
done in Kozhikode Medical College.
Investigations included CBC with
ESR, urine analysis, RFT, LFT, ECG,
Chest X ray, FBG, PPBG, CD4 count,
sputum examination, Tuberculin test,
Ultra sonogram Abdomen, CT scan,
MRI scan, pleural and ascitic fluid
study, CSF study, FNAC, Biopsy and
Echocardiogram. The CD4 cell counting
machine (Partec flow cytometer )
is available in the Department of
Microbiology, Government Medical
College, Kozhikode sanctioned for ART
clinic .The reagent used is CD4 m Ab
PE and the result will be available on
the next day. Investigations were done
according to the clinical presentation
and indication in each patient. OI were
diagnosed as per the standard criteria.
Data was entered and analyzed
by using SPSS software. Qualitative
variables were presented as frequency
and percentage. Strict confidentiality
was maintained regarding the identity
of each patient.
Results
A total of 424 newly detected HIV
patients were clinically assessed for
opportunistic infections in the study.
The source of the cases was either ART
clinic of the Department of Medicine or
Medicine wards in Government Medical
College, Kozhikode. Of the 424 newly
detected HIV patients screened, 100
patients had opportunistic infections
and a detailed study of them was done.
In this study majority of the patients
were male hetero sexuals. The age and
gender distribution is shown in Table
1. It was observed that the majority
were between the age groups of 30-49
yrs (67%) and 71% were males and 29%
were females with a male to female
ratio of 2.44:1.
All patients were presented with
multiple symptoms. Symptoms at
presentation were weight loss (77%),
fever (67%), muco-cutaneous lesions
(60%), cough (41%), breathlessness
(33%) and diarrhea (16%). 22% patients
had headache and 19% had seizure.
Altered sensorium was present in 14%
patients (Table 2).
Most common skin manifestation
wa s c a n d i d i a s i s ( 5 2 % ) f o l l o we d
by seborrhoeic dermatitis (12%).
Tuberculosis (26%) was the frequent
respiratory problem followed by
PCP (15%).15 patients had isolated
pulmonary tuberculosis and 11 patients
had disseminated tuberculosis (DTB).
Eight patients had extra pulmonary
tuberculosis. Fourteen patients had
CNS tuberculosis and 2 patients
had pericardial effusion which was
tuberculous in aetiology. Sputum AFB
was negative in 76% of pulmonary
tuberculosis cases. Among the patients
with tuberculosis 11 patients had non
homogenous opacity in chest x-ray
and 5 had miliary mottling, 6 had
pleural effusion. Oral candidiasis (52%)
was the commonest gastrointestinal manifestation. Chronic diarrhea was
present in 9 patients. There were 9
patients with HBsAg positivity. Stool
examination of the patients with chronic
diarrhea showed cryptosporidium in 5
patients and Isospora belli (Figure
5) in 2 patients. Most frequent CNS
manifestation was tuberculosis (14
patients). CNS toxoplasmosis was
present in 5 persons and 2 patients had
Cryptococcal meningitis (Figure 4). The
various clinical manifestations were
shown in Table 2.
Oral candidiasis (Figure 3) was the
commonest opportunistic infection. It
was present in 52 patients. Among the
100 patients with OI, 50 patients had
tuberculosis. Pneumocystis carinii.
Pneumonia (PCP) was present in 15
patients. Ten patients had bacterial
pneumonia. Other infections are shown
in Figure 1.
CD4 count ranged between 2/microL
to 892/microL. Majority of the patients
had a CD4 count between 50-200/
microL. The CD4 count at various OI
presented were shown in Table 3.
Out of the 100 patients 19 patients
expired. Most common cause of death
was tuberculosis (10 patients). 3
patients with PCP expired. All cases of
PMLE (2) and cryptococcal meningitis
(2) died.2 patients with toxoplasmosis
also did not survive (Figure 2).
Out of the 424 cases with newly
detected HIV infection 100 patients had opportunistic infections. Incidence
calculated as 23.59/100 person years in
this study.
In the present study, among OI in
HIV infected people at presentation,
age group ranged from 20-50 yrs
which represents the most active
and productive group of the society.
Majority were males (79%).These
o b s e r va t i o n s a r e c o m p a r a b l e t o
another study from India by Nilanjan
chakraborty et al.3
In the present study
most common symptom of presentation
was weight loss (77%) followed by fever
(67%) and skin and mucosal lesions
(60%) which is similar to a study by
Singh A et al.4
The high proportion of
weight loss, fever and cough can be due
to the high incidence of tuberculosis in
this study group.
The most common muco-cutaneous
manifestation was oral candidiasis. This
was present in 52% of patients. In many
of the unsuspected cases of retroviral
infection oral candidiasis prompted
the diagnosis. Some of the patients had
multiple muco-cutaneous lesions like
candidiasis, oral ulcers, seborrhoeic
dermatitis. Kaposi’s sarcoma was not
detected in any of the subjects in the
present study. This may be due to the
decreased prevalence of the causative
organism HHV-8 which predominantly
spreads through homosexual contact.
Homosexual mode of transmission is
reported only in 6 patients in our study.
Pulmonary tuberculosis was the
commonest respiratory infection.
Eleven patients had disseminated
tuberculosis (DTB) and 8 had extra
pulmonary tuberculosis.5
The major
symptoms at presentation were weight
loss, fever and cough. 75% of patients
with tuberculosis were Mantoux test
negative. This can be attributed to
the immune suppression in HIV-TB
co-infection and Mantoux test will not
be a useful aid in tuberculosis in HIV
infection. Sputum AFB was negative
in 76% of the tuberculosis cases. It was
observed that many patients became
positive for AFB in sputum after
starting on HAART. This shows the
improving immunity of these patients.
Patients with high CD4 count have
classical findings in chest x-ray. When
CD4 count is low X-rays have lower
zone involvement, miliary shadows and
pleural effusion.6
Most of the patients with PCP
infection had a lower CD4 count
and it was diagnosed clinically.
Main symptoms were dry cough and
breathlessness. Typical interstitial
pattern of chest x-ray, high serum LDH
(Lactate dehydrogenase) and ABG
(Arterial blood gas) abnormality were
present in these patients. There is a 5-7
fold increase in bacterial pneumonia in
HIV patients compared to the general
population. The clinical presentation
was similar as in the HIV non infected
patients.7
Chronic diarrhea was present in
9 patients, which is much less when
compared to the incidences reported
by other Indian studies. This could be
the reflection of better sanitary and
environmental hygiene present in
Kerala. In a study by Anant A Takalkar
et al8
about OI in HIV 30.1% patients
had chronic diarrhea. The mainstay
of therapy in chronic diarrhea of HIV
positive individuals in countries where it is economically and socially feasible is
with highly active ART (HAART) which
was instituted in our patients also. In
our study, most common organism
was cryptosporidium. In a study on
chronic diarrhea in HIV patients by S.V.
Kulkarni et al9
showed that commonest
organism was cryptosporidium. Nine
patients had HBsAg positivity. HIV
infection increases the risk of chronic
carriage of HBV infection and we need
to ensure the screening of Hepatitis B
in HIV patients.10
Neurological manifestations were
present in 23% of the cases. There
was higher incidence of tuberculous
m e n i n g i t i s w h e n c o m p a r e d t o
western reports due to the increased
incidence of this disease in general
population. The clinical course of
CNS tuberculosis in HIV patients is
different from HIV negative patients.
Cryptococcal meningitis was present
in 8.7% of patients with neurological
m a n i f e s t a t i o n . T h e w o r l d w i d e
incidence is 6-12%.Toxoplasmosis
was present in 5% of the patients with
opportunistic infections. In Europe
the most common OI involving CNS is
toxoplasmosis affects 20-40% of all the
AIDS patients.
Progressive multifocal leucoencephalopathy
(PMLE) was present
in 2%.The worldwide incidence is
2-3%. Patients with this disease showed
cognitive impairment and a sequence of
variable focal deficits. Various studies
showed that PMLE is exclusively seen
in immune compromised groups. It
is currently one of the AIDS defining
illnesses in HIV infected patients.
The CD4 cell count is an important
investigation in the clinical evaluation
of any patient with HIV infection
as it helps to decide the stage of the
disease and in decisions regarding anti
retroviral treatment and prophylaxis
against OI. As the tuberculosis is
endemic in India it may occur at any
CD4 count. Most of the disseminated
tuberculosis and CNS tuberculosis had
a CD4 count below 100.
Majority of the bacterial pneumonia
had a CD4 count 200-500/microL and
the clinical presentation was similar to
general population. Oral candidiasis
was occurred in a wide range of
CD4 counts and the incidence is very
high when CD4 count is below 200.
Patients with CD4 count below 100 had
OI like cryptococcal meningitis and Toxoplasmosis. These observations are
comparable to another study by Vinay
KV et al.11
Out of the 100 patients 19 patients
expired. In this study most of the
expired patients had lower CD4 count.
Cryptococal meningitis and PMLE
had 100% mortality. Disseminated
tuberculosis had a high mortality rate
in this study. Most of the patients
w i t h C N S t u b e r c u l o s i s e x p i r e d .
T o x o p l a s m o s i s a l s o h a d a h i g h
mortality. Even if initiation of ART
results in the suppression of OI, issues
of non adherence, ART drug resistance
and treatment failure also exist and
might not be able to totally prevent
or avert OI among the HIV infected
patients. In this study incidence
calculated as 23.59/100 person years.
In a study by Manisha Ghate et al12 the
incidence was 36.8.
In another study from Brazil, had an
incidence 51/100 person years. In other
studies incidence ranges from 10.7-
69.7/100 person years. Oral candidiasis
and tuberculosis had a high incidence
rate in this study. The incidence of OI
is higher in the older age group, in
males and among patients with low
CD4 count.
Conclusion
Oral candidiasis is the commonest
opportunistic infection in HIV infected
patients and is the first indicator of
underlying immunodeficiency in
majority of the cases. Tuberculosis is
the second most common opportunistic
infection and major cause for meningitis,
lymphadenitis and respiratory disease.
Chronic diarrhea is rare in our people
compared to other states of India and
HBV co-infection is common in HIV
patients. The incidence of opportunistic
infection is higher in the older age
groups, males and patients with low
CD4 count.
Limitations of the study are PCP is
diagnosed mainly by clinical assessment
Recommendations
There should be skilled staff and
adequate medications needed for
prophylaxis and management of
OI. Strengthening of the TB-HIV
collaboration activity is very important.
References
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