Complications of HIV Infection - Opportunistic Infections

Opportunistic infections are germs that take the opportunity to infect someone with a poorly functioning immune system. Although these infections can occur during any time of HIV infection, they are most likely to infect a person with AIDS or a very low CD4 count.

Pneumocystis Carinii Pneumonia (PCP)

PCP is the most common opportunistic infection seen in children with HIV. However, it can affect people of all ages with HIV who have low CD4 counts. PCP is a life-threatening disease and once a person develops PCP, they are diagnosed with AIDS for the rest of their lifetime.

PCP is a type of lung infection or pneumonia. The most common symptoms come on slowly and appear as tiredness, fever, cough, and eventually, difficulty breathing. A chest x-ray can show pneumonia but to identify which type of germ is causing that illness may require additional tests. The good news is that there is treatment available. However, people who develop PCP often will be very sick and may require a ventilator to help them breathe. To avoid getting PCP, children who have had the disease before or those who have very low CD4 counts for their age will receive an antibiotic called Septra or Bactrim to hopefully keep them from getting PCP. This is called prophylaxis.

Thrush

Infants and children who have HIV are more likely to develop a condition of the mouth called thrush. This is a yeast infection of the mouth that can be seen on the tongue and the inside of the cheeks. It appears as white patches on the inside of the mouth that look like left over milk. It can often be quite painful, causing the child to have difficulty eating and drinking. A bland diet may be easier for the child to tolerate. It should also be noted that thrush can occur in babies with a normal immune system or normal CD4 counts.

Thrush is treated with a liquid medication called Nystatin. When giving this medication to an infant or young child, half of the dose should be given in each side of the mouth. Pacifiers and nipples from baby bottles and pacifiers should be boiled each day to decrease the chances of re-infection. Older children should be encouraged to swish the medication around the mouth and then to swallow it. If the medication does not get rid of the thrush other medications may need to be used.

The same germ that causes thrush can also cause a vaginal yeast infection. This may cause burning and itching around the vagina and a thick white discharge. It may also be seen as small raised bumps in the diaper area of an infant. There are creams and suppositories available to treat this type of infection, but the best way to prevent this problem is good control of HIV infection by being compliant with medications. Another place that this germ can cause problems is in the esophagus (or the tube that connects your mouth to your stomach). This is called candidal espohagitis and may be associated with symptoms like painful swallowing and burning of the chest. It should be reported to the health care team so further tests can determine if it is present. When a child has candidal esophagitis, it can be a very serious medical problem and requires extensive treatment.

Lymphoid Interstitial Pneumonitis (LIP)

LIP is a "silent" form of pneumonia or lung inflammation that is sometimes seen in children who are over one year of age and who are HIV positive. It occurs when there is an inflammation of the lungs but it is not caused by a particular germ.

This inflammation can limit the oxygen supply in the lungs. It is a progressive problem and there is no specific treatment for LIP. How fast it progresses is different for each person. As the problem gets more advanced, the individual may not be able to get as much oxygen and may feel winded with exercise and get a bluish discoloration of fingernails and toenails. LIP is most likely to be serious in patients with very low CD4 counts or a virus that is poorly controlled.

Cryptosporidiosis

Crytosporidium is a germ that can sometimes cause severe diarrhea and fevers in people with a weak immune system. There is no good treatment available for this illness. Since it is found in contaminated food or water, it is best to avoid it by only drinking tap or bottled water that has been treated or by eating only foods that are properly prepared.

Mycobacterium Avium Complex (MAC)

MAC is an infection that is seen in people with very advanced HIV/AIDS. These people have very high viral loads and very low CD4 counts. Symptoms can be vague and generally develop rather slowly over a few weeks. The symptoms include fever, weight loss, night sweats and feeling tired. The bacteria that causes MAC is found all over the environment, in water, and even in some animals. If a person has a CD4 count less than 50, it may be necessary to take an antibiotic to try and prevent getting sick with MAC. This is called antibiotic prophylaxis.

Herpes Viruses

There are several different germs in the herpes family. As a matter of fact, it has been estimated that 80% of all people have been infected with some kind of herpes virus by the age of 40. Therefore, most people infected with HIV are likely to develop some kind of herpes virus at some point in their life.

Herpes simplex virus can show up as either cold sores, infections of the eye, or genital infections. Varicella (the virus responsible for chicken pox and also a member of the herpes virus family) infections can show up as either very serious chickenpox or as shingles. People with weakened immune systems can get very severe infections with these germs. Therefore, it is very important if your child is exposed to chicken pox that you call the office immediately. There is a shot that we can give to try to prevent the child from getting chicken pox or from getting an extremely severe case. The shot must be given within 96 hours of the exposure. For children who get herpes infections or chicken pox, it is important that you notify the care team immediately since there is a medication called acyclovir that can be used to treat the illness. Acyclovir can be given by mouth or by IV depending on how serious the infection is.

Cytomegalovirus or CMV is one of the herpes viruses that can affect different organs of the body but most often affects the eyes. A warning sign of CMV infection in the eyes is the increased complaint of "floaters" in the eye. While CMV is very common in all people it usually only causes significant problems in people with HIV who have CD4 counts less than 100. Symptoms of CMV include fever, muscle pain, weight loss, and low white blood cell count. There is a medication called gancyclovir that can be used in treatment of CMV. Once treatment is started, it usually must be continued for life.

Histoplasmosis

Histoplasmosis is a disease that is caused by a fungus. It lives in the soil and is spread by bird and bat droppings. It is very common in the state of Indiana. Most of the time, histoplasmosis does not cause illness in healthy people. In people with an abnormal immune system, histoplasmosis can be very severe and affect any organ in the body. The symptoms include fever, weight loss, cough, and swollen lymph glands. It is important that all people with low CD4 counts avoid activities that increase their chance of getting histoplasmosis. This includes activities that disturb the soil such as digging or raking, or being exposed to bird or bat droppings such as playing in an uncovered sandbox or exploring caves. Since fungus germs often live in the soil, construction sites or houses undergoing remodeling should be avoided.

Toxoplasmosis

Toxoplasmosis is a common infection among people living with HIV/AIDS. It usually affects the nervous system, particularly the brain. Although people who are HIV negative can get this infection, you are much more likely to get sick from it with a weakened immune system. The most common symptoms are headache, confusion, and fever. Other symptoms may include seizures, falling, and nausea.

Toxoplasmosis can be spread by eating undercooked meat or by contact with infected cat stool. The infected cat may not appear sick. To protect yourself from getting toxoplasmosis, meat should be cooked to 150 F or until it is no longer pink in the center. Red meat such as steak or hamburger is also safe if it has been frozen for at least 24 hours, or if it is smoked or cured. Chicken, eggs, or other fowl are almost never a risk for toxoplasmosis. Hands should be washed well after touching any raw meat or after any gardening or outdoor activities. All fruits and vegetables should be well washed before eating them raw.

If there is a cat in the child's household, special precautions should be taken, although it is not always necessary to give up your cat. Someone who is not infected with HIV and is not pregnant should take responsibility for changing the litter box every day. If a child infected with HIV must change the litter box, gloves should be worn and hands washed with soap and water right after changing the litter. If a person with HIV cannot find someone to take over these duties, keeping the cat should be reconsidered. It is best to keep a cat indoors to prevent it from hunting and picking up germs. If you adopt a new cat, it should be older than one year and be documented to be healthy by a veterinarian. Stray animals should be avoided.

If a child has a CD4 count of less than 100, antibiotic prophylaxis may be started depending on the age of the child and risk of getting the disease. If a child becomes ill with toxoplasmosis, there is antibiotic treatment available. Once the diagnosis of toxoplasmosis has been made, medication will need to be continued for life.

Other Opportunistic Infections

There are some other infections that take the opportunity to cause illness when someone has a weakened immune system. These include: tuberculosis and cervical or anal disease such as dysplasia or even cancer. Therefore, periodic tests or examinations will be done by the health care team to look for these other problems in those people at risk.