Diarrhea is common in resource-poor settings, especially where access to clean water is unreliable.^80–82 As previously noted, chronic diarrhea may be an indication for starting ART.⁸³ Common diarrhea-causing bacterial infections (such as that caused by Salmonella typhi) may be more aggressive and/or invasive in HIV-infected patients.⁸⁴ Diarrhea may also be the presenting feature of other systemic illnesses, especially in children. Management of diarrhea in HIV-infected patients depends on the severity of disease, the acuteness of the diarrhea, and the degree of immunosuppression. (Table 3.4)⁸⁵ The management approaches to acute and chronic diarrhea are summarized in Protocols 3.17 and 3.18. ^86–88 Adequate hydration with either oral rehydration solution or intravenous fluid resuscitation is essential. ⁸⁹ For acute diarrhea, systemic illnesses such as malaria must first be ruled out. If the patient is very ill, the care provider should not wait for culture results before initiating empiric therapy.

Source (Tables 3.4-3.6): Sande MA, Volberding PA, eds. The medical management of AIDS. 5^thed. Philadelphia, PA: W.B. Saunders and Company, 1997.

Although persons with HIV are at increased risk for coagulopathies and pulmonary emboli⁹⁰ and may have cardiomyopathy, pericardial effusion, or clinical congestive heart failure,⁹¹ when patients complain of dyspnea it is most commonly an acute or subacute infectious process of the lung.^92,93 Tuberculosis is the most common pulmonary complication in this population; note, however, that TB presents with chronic rather than acute shortness of breath under these circumstances more often than not. Table 3.5 summarizes the differential diagnosis of infectious pulmonary syndromes.

In resource-poor settings, evaluation of shortness of breath may be limited to a detailed clinical examination, sputum examination, and basic chest radiograph; if available, computerized tomography (CT) scanning of the chest and echocardiography may be useful. The ability to specifically diagnose the pathogen causing an OI may be limited; thus, recognizing common clinical and radiographic patterns is critical for the prompt implementation of appropriate therapy. Infectious etiologies can be segregated by immunologic state and presentation.⁹⁴ Clinical evaluation and management of patients with shortness of breath is outlined in Protocol 3.19. Protocol 3.20 presents an evaluation algorithm for chest radiography.

The infection commonly known as zoster is caused by the varicella-zoster virus (VZV), a member of the herpes virus family. Most people infected with VZV are infected as children (when the virus presents as chicken pox). The virus remains dormant within the body, living in the nerve root ganglion. When a person’s immune system is compromised, VZV can reactivate and cause the clinical syndrome known as shingles, which presents as a rash with a dermatomal distribution beginning with pain and developing into a papulovesicular eruption that later scabs and crusts. In some cases, the rash may spread across two or more dermatomes (disseminated varicella), at times encompassing the whole body. While uncommon, disseminated varicella can be seen in patients with HIV and is more serious than the common zoster infection.

Zoster is common among HIV-positive patients, even those with preserved CD4 counts; thus, it is frequently a presenting diagnosis that prompts HIV testing.⁹⁵ Disseminated, recurrent, or chronic zoster, accompanied by neurologic complications, are more common at low CD4 counts. In areas where CD4 counts are not available, these complications should prompt the initiation of PCP prophylaxis. ⁹⁶

Herpes simplex is also more common among HIV-infected patients, presenting as a painful cluster of vesicles. Lesions may be peri-oral or genital. Chronic, ulcerative lesions and frequent recurrence are associated with advanced immunosuppression.⁹⁷

An approach to managing herpes infections is summarized in Protocol 3.21.^98,99

Candidal infections occur frequently in patients with HIV.¹⁰⁰ These infections are often a worrisome sign of immunosuppression and signify the need to initiate Pneumocystis prophylaxis. In resource-poor settings—especially those without CD4 monitoring capacity—candidal infections may also signify the need to start ART.

The oropharynx and esophagus are common sites of candidal infection. Patients often present with whitish plaques and difficult or painful swallowing.^101,102 For women with HIV, vulvovaginal candidiasis can be quite severe, often presenting with vaginal discharge and itching; please refer to Section 2.6.3 and Protocol 2.7.¹⁰³

Candida albicans is the most common cause of candidal infections, although in patients with HIV the non-albicans species—which may be resistant to common antifungal agents—are more common.¹⁰⁴ An approach to managing oral and esophageal candidal infections is summarized in Protocol 3.22.

Neurologic complications of HIV disease can be successfully managed using a diagnostic method based on clinical presentation.¹⁰⁵ First, mass lesions, meningitis, and other OIs must be ruled out. The most important clinical distinction is determining whether the presentation represents focal neurologic changes suggestive of a mass lesion, meningitis, or nonfocal or global mental status changes.¹⁰⁶ Imaging of the brain may be difficult to obtain in resource-poor settings; therefore, a careful clinical exam—including an examination of the retina for papilledema—is critical, as are any specific neurologic findings.¹⁰⁷

Protocols 3.23, 3.24, and 3.25 summarize the approach to managing HIV-positive patients who present with neurologic symptoms.^108–110 In addition to the diagnoses reported here, patients should be evaluated for drug side effects, psychiatric illness, and systemic illness (including hypoxia, sepsis, uremia, acid-base disturbance, and hepatic encephalopathy).^111,112

As in any population suffering from chronic illness, HIV-positive patients often experience mental health problems.¹²⁵ In order to determine if a change in mental status stems from a pre-existing medical or psychiatric disorder or is caused by HIV or an OI, any acute or chronic change in mental status must be evaluated immediately.

Depression is a common reaction to the diagnosis of a life-threatening and stigmatizing disease such as AIDS. Economic stressors and social upheaval, which may worsen once the patient falls ill, are often the very situations that put people at risk for HIV infection. Depression can be debilitating and should never be discounted as a “normal” reaction to diagnosis or progression of disease.¹²⁶ Rather, depression should be treated with counseling and selective serotonin re-uptake inhibitors (SSRIs) or other antidepressants, when available. Anxiety is also common among HIV-positive patients and should be treated after biological causes have been ruled out. Other mental health disorders that are not more common in HIV-positive persons—such as schizophrenia and bipolar illness—should also be considered and, if diagnosed, treated.¹²⁷

Psychosocial issues affecting HIV-positive patients and their families are often overlooked by providers but should in fact be addressed as part of a comprehensive treatment plan.^128,129 Although Table 3.9 divides the occurrence of these issues into early, middle, and late phases, any of these issues may present during any stage of disease progression.

Source: Forstein M. Psychiatric problems. In: O’Neill JF, Selwyn PA, Schietinger H, eds. A clinical guide to supportive and palliative care for HIV/ AIDS. United States Department of Health and Human Resources, Health Resources and Services Administration, 2003:207–52.

Immune reconstitution syndrome refers to a paradoxical worsening of a patient’s clinical status that can occur after the initiation of ART.¹³⁰ The worsening of symptoms is due to improved function of the patient’s immune system, resulting in the system’s ability to mount an inflammatory response to infectious pathogens and neoplasms.¹³¹ Immune reconstitution syndromes have been reported in patients with Mycobacterium avium complex, ¹³² TB, ¹³³ Cryptococcus neoformans,¹³⁴ cytomegalovirus (CMV),¹³⁵ PCP,¹³⁶ and a host of other AIDS-related malignancies.¹³⁷ The differential diagnosis of a patient who presents with worsening symptoms and is newly started on ART should include an adverse reaction to a drug, a new or previously unrecognized OI, and failure of OI therapy. Once other causes of worsening symptoms have been ruled out, management of patients almost always includes continuation of ART, treatment directed at the specific OI affecting the patient’s immune system, and the occasional use of anti-inflammatory agents. Care should follow the approach outlined in Protocol 3.26.¹³⁸

Problems of the skin and mucous membranes may affect up to 90 percent of HIV-infected people and can occur at all stages of the disease. Mucocutaneous reactions may be associated with the HIV virus itself, immunologic effects of the disease, OIs, or the medications used to treat HIV. All patients who present with cutaneous mucuous membrane problems should be questioned as to the duration of the problem; the presence of itching, pain, bleeding, discharge, lumps, or sores; and recent sexual history. The patient should also be questioned as to whether her partner(s) or family members have similar symptoms. Appendix F presents an overview of dermatological conditions common among HIV-infected patients.