A Quick Review of AFP's "Complications of HIV Infection: A Systems-Based Approach "

A brief synopsis of:Complications of HIV Infection: A Systems-Based Approach  
CAROLYN CHU, MD, MSc, and PETER A. SELWYN, MD, MPH Albert Einstein College of Medicine of Yeshiva University, Bronx, New York 
Am Fam Physician. 2011 Feb 15;83(4):395-406. 
http://www.aafp.org/afp/2011/0215/p395.pdf

     HIV doesn't kill you. Its the complications that do. Managing patients with HIV includes monitoring antiretroviral therapy, preventing and treating opportunistic infections, and treating related chronic complications. A careful review of preexisting conditions, current CD4 count, medication list, and recent exposures/ behaviors is an important part of management. This article will discuss the neurological,  cardiopulmonary, and gastrointestinal  complications.
     CNS problems are considerations in the HIV patient. The most common infections are toxoplasmosis, cryptococcus neoformans, JC virus, CMV, HSV,  and syphilis.   The symptoms vary widely, but most include focal neurological deficits, headache, fever and confusion. The CD4 count is a good place to start the differential. Neurosyphilis can invade when the CD4 count drops below 350. The typical tests (CSF VDRL, treponemal) are employed. The CSF will show elevated proteins and increased mononuclear pleocytosis. At 200, the JC virus or HSV can be involved. The JC virus can cause progressive multifocal leukoencephalopathy. CT or MRI show single or multiple white matter lesions with no edema, mass effect, or enhancement. HSV will show diffuse edema, as well as frontal or temporal necrosis. At 50, CMV, toxoplasmosis, and cryptococcal meningitis come into play. CMV will show periventricular enhancement on MRI. The cryptococcal antigen will be positive in the serum and elevated in the CSF of cryptococcal infected patients. Toxoplasmosis patients will have a ring enhanced lesion and edema on head imaging. Serum IgG will also be positive. Other than infections, lymphoma can cause CNS symptoms. Imagining may show a solid white matter mass with edema and mass effect.
     Dementia is an AIDS-defining condition. Diagnosis requires abnormalities in motor or behavioral function that impairs ADLs, along with a deficit in any two of the following areas; memory, attention and concentration. Psychiatric and substance abuse are also prevalent.
     Radiculopathy and neuropathy are elevated in HIV patients. Radiculopathy presents as radiating neck pain, leg weakness, leg sensory loss, bowel or bladder issues. Neuropathy presents as paresthesia, dysesthesia, or bilateral peripheral numbness.  The physician should evaluate this through testing deep tendon reflexes, vibration, EMG, NCV or MRI.
     Atherosclerosis and myocardial infarction should also be evaluated. HIV can increase cytokine levels, vascular inflammation, and endothelial dysfunction. Antiretroviral medications, such as abacavir, can cause cardiotoxicity. Elevated cholesterol combined with HIV and antiretroviral medications can affect the cardiovascular system.
     Pneumonia from Pneumocystis jiroveci presents with fever, dyspnea and cough. It arrives when CD4 counts drop below 200. Imaging will show bilateral interstitial infiltrates. If empiric treatment fails after 4 -5 days, then atypical causes should be investigated, such as Legionella.
    HIV patients who smoke have an increased risk of emphysema over non-infected patients. COPD is increased as well. HIV associated pulmonary hypertension is another complication that exists. The evaluation is the same as in non HIV infected patients.
      The oral cavity and esophagus can be a battlefield for infection as well. Candidal colonization is common, causing thrush. At CD4 count below 200, CMV and HSV can produce aphthous ulcers, oral ulcers and esophagitis. Patients should be checked for oropharyngeal cancer in this case.
     Diarrhea is a common symptom in HIV related gastrointestinal complications. HIV can directly affect gut motility,  causing enteropathy ( at a CD4 <200). CMV and cryptosporidium are seen when the CD4 drops below 100. Diarrhea can also be from protease inhibitors or intestinal malignancies. Protease inhibitors can also cause pancreatitis and nephrotoxicity.  Renal disease can also be HIV associated. Renal function should be assessed early in the diagnosis of HIV. Worsening renal function can be addressed with (non-nephrotoxic) antiretrovirals, ACEIs and steroids. Kidney transplantation may be an option.
     Endocrine complications are also seen in HIV. Antiretroviral therapy can affect glucose metabolism, lipid metabolism, and fat distribution. Patients need to be screened for glucose and lipid disorders at diagnosis. Choosing medications that don't affect these situations can be helpful. Adjusting medications for the other illnesses is also a good idea. Using pioglitazone, metformin or thiazolidinediones may be beneficial. Other endocrine disorders include adrenal insufficiency, testosterone deficiency, and hypogonadism.
     Osteopenia and osteoporosis have also been a side effect of antiretroviral medication. Bone ischemia from the virus can also lead to osteomalacia and osteonecrosis. Myopathy may be seen when the medications are given with statins, calcium channel blockers or antiepileptics. Myopathy from nucleoside analogues is no longer an issue since the development of newer treatments.