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Lecture 7

Prepared and presented by
Marc Imhotep Cray, M.D.

Scanning electron micrograph of Staphylococcus aureus bound to the surface of a human neutrophil. “Granulocytic Phagocytes,” by Frank R. DeLeo and William M. Nauseef.
Companion reading, audio, and video
1. Kishiyama JL. Ch. 3 Disorders of the Immune System, AIDS Pgs. 53-57 In: Hammer GD and McPhee Eds. JS.
Pathophysiology of Disease : An Introduction to Clinical Medicine, 7th Ed. New York: McGraw-Hill Education, 2014
2. Diseases of the Immune System, Ch.6. Immunodeficiency Syndromes, Acquired Immunodeficiency Syndrome (AIDS).
Pgs.441-463 In: Kumar V and Abbas AK. Robbins and Cotran Pathologic Basis of Disease 8th ed. Philadelphia:
Saunders, 2014
3. Robbins and Cotran Pathologic Basis of Disease 8th ed. Audio Ch. 6 -Immunodeficiency Syndromes, Acquired
Immunodeficiency Syndrome (AIDS) section.

Highly Recommended: Video Animations (Mechanisms of Medicine Inc.)
HIV and AIDS Clinical Pharmacology
HIV Infection and AIDS  Mechanisms of Action of Non-Nucleoside Reverse Transcriptase
(On Thumb drive.) Inhibitors (NNRTls)
 Basic Function of Immune System  Mechanisms of NNRTI Resistance
 Adherence and Resistance Issues with HIV Drug  Mechanisms of Action of Nucleoside Reverse Transcriptase
Treatment Inhibitors (NRTls)
 Diagnosis and Testing of HIV Infection  Mechanisms of NRTI Resistance (Nucleoside Analogue
 How HIV Causes Disease Discrimination)
 Transmission and Prevention of HIV  Mechanisms of NRTI Resistance (Primer Nucleoside Unblocking)
 Viral Load and Monitoring  Mechanisms of Action of Protease Inhibitors (PIs)
 Mechanisms of PI Resistance 2
Acquired Immune Deficiency Syndrome (AIDS)
Introduction
 Infection with HIV causes a continuum of diseases, from acute (primary) HIV
infection  prolonged periods of asymptomatic infection  full blown AIDS
 Diagnosis of AIDS implies there has been significant damage to immune
system and is a surveillance case definition established by Centers for Disease
Control and Prevention (CDC) as part of classification of clinical status of HIV-
infected patients
 To date, two types of HIV, HIV-1 and HIV-2, have been identified as causative
agents of AIDS
 There are several subtypes (clades) of HIV-1 with varying distributions throughout world,
whereas HIV-2 is more prevalent in Western Africa

Important Epidemiology Note: “The Pandemic of HIV continues to be a serious international problem
As of 2005, there were about 38.6 million people worldwide living with HIV/AIDS, with 2.8 million
deaths in 2005 and 4 million people newly infected with HIV.”
U.S. CDC (Centers for Disease Control and Prevention) http://www.cdc.gov/HIV/
Marc Imhotep Cray, M.D. 3
Prevalence of human immunodeficiency virus (HIV) infection among the adult population worldwide.
World Health Organization (WHO) figures from 2006 demonstrate the extent of the HIV pandemic throughout the world.

Rubin R and Strayer DS Eds. Rubin’s Pathology: Clinicopathologic Foundations of Medicine, 2012
Marc Imhotep Cray, M.D. 4
Acquired immunodeficiency syndrome (AIDS)
 AIDS is an infectious disease caused by human immunodeficiency viruses
(HIV)
 AIDS is characterized by a profound suppression of immune system and
susceptibility to infections, neurologic disorders, and malignancies

Main characteristics of HIV
 Two genetically different, but closely related forms of human pathogens
are recognized: HIV-1 and HIV-2
 Both are RNA viruses belonging to retrovirus family
 HIV expresses cell surface protein gp120, which binds to CD4+ surface
molecule of T helper lymphocytes
 Proviral DNA synthesized by a reverse transcription in infected cells is
integrated into host’s nuclear DNA
Marc Imhotep Cray, M.D. 5
Structure of HIV (simplified)

Ireland KA. Visualizing Human Biology, 3rd ed. New Jersey: Wiley & Sons, 2011

Marc Imhotep Cray, M.D. 6
Structure of HIV (2)
 Similar to most retroviruses, HIV-1 virion is spherical and
contains an electron-dense, coneshaped core surrounded by
a lipid envelope derived from host cell membrane
(enlarged next slide)
 The virus core contains
(1) the major capsid protein p24
(2) nucleocapsid protein p7/p9
(3) two copies of genomic RNA; and
(4) three viral enzymes (protease, reverse transcriptase, and
integrase)
p24 capsid is most readily detected viral antigen and is target
for antibodies that are used for diagnosis of HIV infection in
Kumar V and Abbas AK. Robbins and Cotran
widely used enzyme-linked immunosorbent assay (ELISA) Pathologic Basis of Disease 8th ed. 2014
 Viral core is surrounded by a matrix protein called p17,
which lies underneath virion envelope
 Studding viral envelope are two viral glycoproteins, gp120
and gp41, which are critical for HIV infection of cells

Marc Imhotep Cray, M.D. 7
HIV genes, gene products & structure of HIV-1 virion
HIV is a group of related retroviruses, whose
RNA encodes for nine genes

Modified from: Hammer GD and McPhee JS, Eds. Pathophysiology
of Disease : An Introduction to Clinical Medicine, 7th Ed. 2014
8
Kumar V and Abbas AK. Robbins and Cotran Pathologic Basis of Disease 8th ed. 2014
HIV reproduction (simplified)
1. Virus attaches to host cell at CD4 receptor
2. Viral RNA is injected into the cell and
using reverse transcriptase makes a
complementary DNA strand (cDNA)
3. Viral cDNA makes a second strand of DNA
The double-stranded viral DNA enters the
nucleus and is inserted into the host DNA
where it can remain dormant for many
years as a provirus
4. Viral cDNA is transcribed into viral RNA
and exported into the cytoplasm.
5. Viral RNA is translated into new viral
particles
6. Assembled virus buds from the cell
membrane and is released
Marc Imhotep Cray, M.D. Modified from: Ireland KA. Visualizing Human 9
Biology, 3rd ed. New Jersey: Wiley & Sons, 2011
Case Trigger
A 25-year-old man comes to your office, for the first time in many years, with
complaints of general fatigue, a headache, muscle aches, and a mild fever. He
states that this has persisted for “4 or 5 days” and that he “just wants to get my
energy back.” He takes no medications.
He appears somewhat tired and shows mild psychomotor retardation. Physical
examination is notable for scattered lymphadenopathy and a small patchy
nonspecific rash on the neck.

What is the differential diagnosis?
Infectious mononucleosis, hypothyroidism, influenza, occult infection,
anemia, depression, acute HIV infection, malnutrition, adrenal insufficiency,
non-Hodgkin’s lymphoma, and dermatomyositis should be considered.

Marc Imhotep Cray, M.D. 10
Case Trigger cont.
You write orders for a battery of standard tests and give the patient
directions to the laboratory. As you are about the leave the room, the
patient stops you and asks, “A few months ago, I started using
intravenous heroin. Do you think that might be related to these
problems?”

Marc Imhotep Cray, M.D. 11
Case Trigger cont.
 HIV infection is now more likely detection of HIV antibodies is accomplished
by enzyme-linked immunosorbent assay (ELISA) the preferred screening
test (high-sensitivity test)
 If ELISA is positive, test must be confirmed by Western blot analysis (high-specificity
test) positive if antibodies from patient’s serum are demonstrated to interact with
HIV-1 proteins displayed on acrylamide gel used in test
 A Western blot must be positive for antibodies to at least two important HIV antigens
(e.g., gp120, gp41, p24)
o If only one antibody is positive result is indeterminate and test must be repeated
after a few months, or an HIV PCR assay must be done

 HIV test results are often falsely positive in newborns born to HIV-infected
mothers because these antibodies can cross placenta but are also often
falsely negative within first few months of infection

Marc Imhotep Cray, M.D. 12
Case Trigger cont.
The results of his HIV ELISA and Western blot test are positive. You continue
to follow-up with him regularly, and 5 years later he comes for another
regularly scheduled appointment with a few questions. You note in his chart
that he has been on highly active antiretroviral therapy (HAART) for a few
years now. He states that he has been reading about the HIV stages, and asks,
“Which stage am I in?” Additionally, he said he heard about “something called
Pneumocystis carinii pneumonia (PCP) that can happen when your CD4+ T-cell
count gets below 200” and requests more information on this topic.
Note:
 Time course for progression of HIV infection is highly variable median time before appearance of
clinical disease is about 10 years in untreated individuals
 Approximately 10% of those infected manifest rapid progression to AIDS within 5 years after infection
 A minority of individuals are “long-term nonprogressors”
 Genetic factors, host cytotoxic immune responses, viral load, and virulence have an impact on
susceptibility to infection and rate of disease progression
Marc Imhotep Cray, M.D. 13
Highly Active AntiRetroviral Therapy (HAART)
 Combination therapy for AIDS with inhibitors of HIV reverse transcriptase, integrase ,
protease, and entry (fusion) are reasonably successful, but associated with long-term
toxicities in almost 50% of persons

 An effective vaccine remains an elusive goal, in part due to rapid mutation rate of virus
during reverse transcription

 There are four (five) classes of antiretroviral drugs, each of which targets one of four viral
processes
1. Reverse transcriptase inhibitors
 nucleoside and nucleotide reverse transcriptase inhibitors (NRTIs),
 nonnucleoside reverse transcriptase inhibitors (NNRTIs),
2. Protease inhibitors (PIs),
3. Entry (fusion) inhibitors, and
4. Integrase inhibitors
 Preferred initial therapy is a combination of two NRTIs with a PI, a NNRTI, or an integrase
inhibitor
Marc Imhotep Cray, M.D. 14
Human immunodeficiency virus and its life cycle
 After attachment to CD4 and a chemokine
co-receptor (usually CCR5), virus membrane
fuses with cellular membrane to allow entry
into cell
 Following uncoating, reverse transcription
of viral RNA results in production of double-
stranded DNA (dsDNA)
 This is inserted into host genome as HIV
provirus, by a virally coded integrase
enzyme
 Cell activation leads to transcription and
production of viral mRNAs
 Structural proteins are produced and
assembled
 Free HIV viruses are produced by viral
budding from host cell, after which further
internal assembly occurs with cleavage of a
large precursor core protein into small core
protein components by a virally coded
protease enzyme, producing mature virus
particles, which are released and can go on
to infect additional cells bearing CD4 and Male D etal. Immunology, 8th Ed. Philadelphia, PA: Elsevier-Saunders, 2014
chemokine co-receptor 15
Highly Active AntiRetroviral Therapy (HAART) cont.
 HAART is often initiated at time of HIV diagnosis
 Although not curative, antiretroviral pharmacotherapy can significantly
reduce viral replication, restore immune function, lead to clinical
recovery, and markedly extend life expectancy

 Strongest indication for patients presenting with AIDS-defining
illness is low CD4+ cell counts (< 500 cells/mm3)

 HAART regimen consists of 3 drugs to prevent resistance:
 2 NRTIs and 1 of the following: NNRTI or protease inhibitor or
integrase inhibitor

Marc Imhotep Cray, M.D. 16
Classes of drugs used in HAART
 First class of antiretroviral drugs includes two types of reverse transcriptase
inhibitors
 (1) Nucleoside analog reverse transcriptase inhibitors (nRTIs) are
incorporated by reverse transcriptase into transcribed DNA strand
where they block further extension of strand and thereby inhibit viral
replication
o They require phosphorylation by thymidine kinase to become active
 (2) Non-nucleoside reverse transcriptase inhibitors (nnRTIs) inhibit
action of reverse transcriptase enzyme but bind at a site other than
catalytic site
o do not require activation by thymidine kinase
 Second class of drugs called protease inhibitors (PIs) mimic peptides that
HIV protease cleaves, but bind more tightly and specifically, thus inhibiting
protease
Marc Imhotep Cray, M.D. 17
Protease inhibitors (PIs)
Agents: MOA: Adverse Effects/Toxicities:
(All PIs end in -navir)  Assembly of virions depends Hyperglycemia, GI intolerance
 Atazanavir on HIV-1 protease (pol (nausea, diarrhea), lipodystrophy
 Darunavir gene), which cleaves Nephropathy, hematuria
 Fosamprenavir polypeptide products of HIV (indinavir)
 Indinavir mRNA into their functional Contraindications:
 Lopinavir parts Rifampin (a potent CYP/UGT
 Ritonavir  Protease inhibitors prevent inducer) contraindicated with
 Saquinavir maturation of new viruses protease inhibitors because it can
Drug-Drug Interaction: decrease protease inhibitor
Ritonavir can “boost” other concentration
drug concentrations by
inhibiting cytochrome P-450
18
Nucleoside reverse transcriptase inhibitors (nRTIs)
Agents: MOA: Adverse Effects/Toxicities:
 Abacavir (ABC)  Competitively inhibit Bone marrow suppression (can
 Didanosine (ddI) nucleotide binding to reverse be reversed with granulocyte
 Emtricitabine (FTC) transcriptase and terminate colony stimulating factor
 Lamivudine (3TC) DNA chain (lack a 3′ OH [G-CSF] and erythropoietin),
 Stavudine (d4T) group) peripheral neuropathy, lactic
 Tenofovir (TDF)  Tenofovir is a nucleoTide; acidosis (nucleosides), anemia
 Zidovudine (ZDV, others are nucleosides and (ZDV), pancreatitis (didanosine)
formerly AZT) need to be phosphorylated
to be active
 ZDV is used for general
prophylaxis and during
pregnancy to decrease risk
of fetal transmission 19
Non-nucleoside reverse transcriptase inhibitors
NNRTIs: MOA: Adverse Effects/Toxicities:
Delavirdine  Bind to reverse  Rash and hepatotoxicity
Efavirenz transcriptase at site are common to all NNRTIs
Nevirapine different from NRTIs  Vivid dreams and CNS
 Do not require symptoms are common
phosphorylation to be with Efavirenz
active or compete with Contraindications:
nucleotides  Delavirdine and efavirenz
are contraindicated in
pregnancy.

Marc Imhotep Cray, M.D. 20
3rd Class Integrase inhibitors
Agent: MOA:
Adverse Effects/Toxicities:
Raltegravir Inhibits HIV genome integration
creatine kinase
into host cell chromosome by
reversibly inhibiting HIV integrase

4th Class Fusion (entry) inhibitors
MOA: Adverse Effects/Toxicities:
Agents:
Enfuvirtide Binds gp41, inhibiting viral entry Skin reaction at
injection sites
Maraviroc Binds CCR-5 on surface of T
cells/monocytes, inhibiting
interaction with gp120

Marc Imhotep Cray, M.D. 21
Question
A 37-year-old man who is HIV-positive recently started on a highly active
antiretroviral regimen(HAART) . The patient’s CD4+ T- cell count subsequently
fell below 200/mm3. Over the course of the next 3 months, he develops
diarrhea and notices a redistribution of fat on his body.
Which of the following agents is most likely causing this patient’s symptoms?
(A) Fusion inhibitor
(B) Non-nucleoside reverse transcriptase inhibitor
(C) Nucleoside reverse transcriptase inhibitor
(D) Nucleotide reverse
(E) Protease inhibitor

Marc Imhotep Cray, M.D. 22
Suboptimal compliance with HAART &
resistance
 Suboptimal compliance with highly active antiretroviral therapy rapidly
leads to resistance. Why?
 Any allowance of continued viral replication (e.g., from missed doses)
is dangerous, because HIV reverse transcriptase enzyme is
extraordinarily error-prone therefore, mutations arise quickly, and
if one leads to drug resistance, it can proliferate rapidly

 In general, nRTI resistance occurs through mutations that prevent
nucleoside analog incorporation or create a mechanism of ATP-
mediated nucleoside analog removal

 Resistance to nnRTIs and PIs usually occurs through mutations that alter
binding sites for these drugs
Marc Imhotep Cray, M.D. 23
HIV modes of transmission
 HIV is transmitted by exposure to infected body fluids or
sexual or perinatal contact , and also through breast-feeding

 Transmissibility of HIV virus related to subtype virulence,
viral load, and immunologic host factors

1. Sexual contact: homosexual (male) and heterosexual (male-to-
female and female-to-male)
2. Parenteral inoculation: intravenous drug abusers and recipients of
blood and blood products
3. Passage from infected mother to child: transplacental spread,
transmission during delivery, and breast-feeding

Marc Imhotep Cray, M.D. 24
Mechanisms of
CD4+ T-cell loss in
HIV infection

Kumar V and Abbas AK. Robbins and Cotran Pathologic Basis of Disease 8th ed. Philadelphia:
Marc Imhotep Cray, M.D. Saunders, 2014 25
Pathogenesis of AIDS
Primary targets for HIV are CD4+ T cells but viruses also invade
macrophages and dendritic cells

HIV binds to CD4 molecule, which acts as a high-affinity receptor
 infection requires coreceptors: CCR5 and CXCR4 (chemokine receptors)

After it is internalized, viral genome undergoes reverse transcription
leading to formation of proviral DNA (cDNA)

In dividing cells, cDNA integrates into host genome

Upon antigenic stimulation, proviral DNA is transcribed and complete virus
particles are produced, which may lead to cell death
 Results in a reduction in CD4+ T cells and persistent productive infection of
macrophages, monocytes, and Langerhans cells
Marc Imhotep Cray, M.D. 26
Life Cycle of HIV (Infection process) reiterated
 gp120 antigen on HIV binds to CD4+ receptors on T cell
 This process produces a conformational change and the need to bind to
a co-receptor: CCR5 or CXCR4
 gp41 binds to co-receptor
 This binding causes ‘six-helix bundle formation’ and fusion of viral and
host membranes
 Disintegration of viral capsid occurs causing viral RNA to be released into
human cell
 Double-stranded RNA is produced and this process is catalyzed by viral
reverse transcriptase
 Double-stranded RNA is integrated into host DNA using integrase enzyme
 Host cell now manufactures new virions by long terminal repeat sequences
and genes tat and rev

Marc Imhotep Cray, M.D. 27
Life Cycle of HIV (2)
 HIV infects cells by using CD4
molecule as receptor and various
chemokine receptors as
coreceptors
 requirement for CD4 binding
explains selective tropism of virus
for CD4+ T cells and other CD4+
cells, like monocytes /
macrophages and dendritic cells
 Binding to CD4 is not sufficient
for infection
 HIV gp120 must also bind to
other cell surface molecules
(coreceptors) for entry into cell
o Chemokine receptors CCR5
(early) and CXCR4 (late),
serve this role
Marc Imhotep Cray, M.D. Kumar V and Abbas AK. Robbins and Cotran Pathologic Basis of Disease 8th ed. 28
Philadelphia: Saunders, 2014
Human immunodeficiency virus-1 (HIV-1) seen
budding from infected cells (arrows)

Rubin R and Strayer DS Eds. Rubin’s Pathology: Clinicopathologic Foundations of Medicine, 2012

Marc Imhotep Cray, M.D. 29
Natural History and Phases of HIV infection
Four major stages of HIV infection:
1. Early, acute phase: Self-limited acute illness 3 to 6 weeks after infection
 High level of virus production and widespread infection of lymphoid
organs

2. Middle, chronic phase: No symptoms or persistent lymphadenopathy for
several years

3. Minor infections

4. Final, crisis: Long-lasting fever, severe opportunistic infections, secondary
neoplasms, and neurologic disease
 This usually develops after 7 to 10 years of chronic phase
Marc Imhotep Cray, M.D. 30
Four major stages of HIV infection cont.
 With acute HIV infection, individual may remain asymptomatic or develop
an acute illness that resembles influenza or infectious mononucleosis
symptoms usually develop within 2 to 6 weeks after infection
 During this stage, antibodies to HIV are generally undetectable
 Seroconversion usually occurs during clinical latency, an asymptomatic
period that would last approximately 7 to 10 years in an untreated patient
 Low-level (but persistent) replication of HIV causes a gradual decrease in CD4+ T cells,
and minor opportunistic infections may occur
 During the crisis phase, escalation of viral replication leads to a more rapid
T-cell decline
 This is clinically apparent as weight loss, fever, fatigue, and lymphadenopathy
 Acquired immunodeficiency syndrome (AIDS) is diagnosis for a person who
is HIV-positive and has a T-cell count below 200 cells/ uL ( or 200/ mm3) or
presents with one of AIDS defining opportunistic infections /malignancies
Marc Imhotep Cray, M.D. 31
Typical course of
HIV infection (1)
Acute HIV infection may present as a
self-limited, febrile viral syndrome
characterized by:
 fatigue
 pharyngitis
 myalgias
 maculopapular rash
 lymphadenopathy and
 significant viremia
 without detectable anti-HIV
antibodies

Kumar V and Abbas AK. Robbins and Cotran Pathologic Basis of
Marc Imhotep Cray, M.D. Disease 8th ed. Philadelphia: Saunders, 2014 32
Typical course of HIV infection (2)

Marc Imhotep Cray, M.D. 33
Rubin R and Strayer DS Eds. Rubin’s Pathology: Clinicopathologic Foundations of Medicine, 2012
Typical course of untreated HIV infection (3)
 During early period after primary infection,
there is widespread dissemination of virus
and a sharp decrease in number of CD4 T
cells in peripheral blood
 An immune response to HIV ensues, with a
decrease in detectable viremia followed by
a prolonged period of clinical latency
 Sensitive assays for viral RNA show that
virus is present in plasma at all times
 CD4 T-cell count continues to decrease
during following years until it reaches a
critical level below which there is a
substantial risk of opportunistic diseases.
Fauci AS, Lane HC: Human immunodeficiency virus disease: AIDS
and related disorders. In Longo DL, Fauci AS, Kasper DL, et al
(editors). Harrison’s Principles of Internal Medicine, 18th ed.
McGraw-Hill, 2012
34
Clinical Presentation
 From 40% to 90% of patients
with primary HIV infection
present with symptomatic illness,
including fever, fatigue,
a rash (typically maculopapular),
headaches, lymphadenopathy,
pharyngitis, nausea, vomiting, and
diarrhea
o These symptoms usually
last for less than 2 weeks

STI and HIV Lab Testing:
ELISA, enzyme-linked immunosorbent
assay; CBC, complete blood count; VDRL,
venereal disease research laboratory;
RPR, rapid plasma reagin
Runge MS and Greganti MA. Netter's Internal Medicine 2nd Ed. Saunders, 2008
Marc Imhotep Cray, M.D. 35
Major Abnormalities of Immune Function in AIDS
 LYMPHOPENIA
 Predominantly caused by selective loss of CD4+ helper T-cell subset
DECREASED T-CELL FUNCTION IN VIVO
 Preferential loss of activated and memory T cells
 Decreased delayed-type hypersensitivity
 Susceptibility to opportunistic infections
 Susceptibility to neoplasms
ALTERED T-CELL FUNCTION IN VITRO
 Decreased proliferative response to mitogens, alloantigens, and soluble
antigens
 Decreased cytotoxicity
 Decreased helper function for B-cell antibody production
 Decreased IL-2 and IFN-γ production
 Diminished capacity to present antigen to T cells
Marc Imhotep Cray, M.D. 36
Major Abnormalities of Immune Function in AIDS
cont.
 POLYCLONAL B-CELL ACTIVATION
 Hypergammaglobulinemia and circulating immune complexes
 Inability to mount de novo antibody response to new antigens
 Poor responses to normal B-cell activation signals in vitro

ALTERED MONOCYTE OR MACROPHAGE FUNCTIONS
 Decreased chemotaxis and phagocytosis
 Decreased class II HLA expression

Marc Imhotep Cray, M.D. 37
Most important determinants of progression
of HIV infection
CD4+ T-cell count indicates damage that has occurred to immune
system, and how close patient is to progressing to AIDS (acquired
immunodeficiency syndrome)
 A high count is ideal
 Normal count ranges from 500 to 1500 cells/ uL (500 to 1500/ mm3)

Viral load is an indication of pace at which damage is occurring
 A low viral load is ideal
 Viral load serves as a marker for disease progression and drug therapy
effectiveness by measuring amount of actively dividing HIV virus

 CD4 count better for disease staging
 Viral load better proxy for disease progression
Marc Imhotep Cray, M.D. or monitoring response to therapy 38
How is clinically suspected diagnosis of AIDS
confirmed
 Laboratory tests are performed to detect antibodies against
HIV proteins

 Seroconversion (presence of antibodies against HIV in a
previously nonreactive individual) usually occurs within 6
months of exposure to HIV

 Detection of infection during serologic window before
seroconversion requires detection of viral antigens or viral RNA

Marc Imhotep Cray, M.D. 39
Common opportunistic infections in AIDS
 Opportunistic infections account for the vast majority of deaths in patients
These infections include:

 P. jiroveci pneumonia
 C. albicans infections of the mouth, esophagus, vagina, and
lungs
 Cytomegalovirus enteritis and pneumonitis
 Atypical mycobacterial infection (M. avium-intracellulare) of GIT
 Cryptococcus neoformans meningitis
 Cryptosporidium enteritis

Marc Imhotep Cray, M.D. 40
Most common neoplasms associated with
HIV infections and AIDS
 Kaposi sarcoma
 Non-Hodgkin lymphoma
 Carcinoma of uterine cervix
 Squamous cell carcinoma of skin

Marc Imhotep Cray, M.D. 41
Neurologic consequences of HIV infection
and AIDS
Involvement of central nervous system is common (clinically 40%–
60%) and may present in several forms:
HIV-related diseases
 Aseptic meningitis
 AIDS dementia complex
Opportunistic infections:
 viral (cytomegalovirus and herpes simplex virus)
 fungal(Coccidioides and Cryptococcus), and protozoal
(Toxoplasma gondii)
Neoplasms (lymphoma)

Marc Imhotep Cray, M.D. 42
Capsule consequences of
HIV infection and AIDS
 Human immunodeficiency
virus-1 (HIV-1) mediated
destruction of cellular immune
system results in  acquired
immunodeficiency

 Infectious and neoplastic
complications of AIDS can
affect practically every organ
system

Marc Imhotep Cray, M.D. 43
Rubin R and Strayer DS Eds. Rubin’s Pathology: Clinicopathologic Foundations of Medicine, 2012
What is “PCP pneumonia”
 PCP refers to Pneumocystis carinii pneumonia (the preferred
name is now Pneumocystis jirovecii pneumonia)
 P. jirovecii pneumonia is most common significant opportunistic
infection in HIV patients
o yeast-like fungus originally classified as protozoan and now
classified as a fungus
 typically occurs in patients with a CD4+ count of below 200

 Pneumocystis jirovecii causes a diffuse interstitial pneumonia

Marc Imhotep Cray, M.D. 44
PCP (2)
 Transmission: Inhaled
 Most infections are asymptomatic
 Immunosuppression (e.g., AIDS) predisposes to disease
 Clin. Findings:
 Patients typically present with fever, nonproductive cough, and dyspnea
 Radiographic studies show bilateral diffuse infiltrates, most pronounced in
perihilar regions
o Diffuse, bilateral ground-glass opacities on CXR/CT
 Diagnosed by lung biopsy or lavage Disc-shaped yeast forms on
methenamine silver stain of lung tissue

 Patients with CD4+ counts below 200/mm3 should be started on TMP-SMX
prophylaxis

Marc Imhotep Cray, M.D. 45
Question
A 23-year-old man presents to the emergency
department with symptoms of malaise, dry cough,
and dyspnea for several weeks. Physical
examination reveals tachypnea, tachycardia, and
fever, with crackles on auscultation. On
further questioning, the patient admits to IV drug
abuse. The chest x-ray findings (top) prompt the
clinician to order a chest CT study, from which is a
representative section in the coronal plane is shown
in the bottom figure.
What is the most likely diagnosis?
A. Pneumocystis pneumonia (PCP)
B. Pneumococcal pneumonia
C. Miliary tuberculosis (TB)
D. Cytomegalovirus (CMV) pneumonia
E. Pulmonary edema

Studdiford, JS and Tully AS. USMLE Images for the Boards:
Marc Imhotep Cray, M.D. 46
Philadelphia. Saunders,2013
Other opportunistic pathogens and
malignancies: Major cause of death in AIDS
Common opportunistic infections at notable CD4+ counts:
 Toxoplasma encephalitis at <100
 Cryptococcal meningitis at <100
 Mycobacterium avium complex at <50
 Cytomegalovirus retinitis at <50
o CMV retinitis is treated with ganciclovir, a competitive
guanosine analog
• In event that ganciclovir fails foscarnet (viral DNA
polymerase inhibitor) is used

Marc Imhotep Cray, M.D. 47
Prophylaxis for opportunistic infections
Based on CD4 count, following algorithm may be used in initiating prophylaxis for serious
opportunistic infections in HIV-infected patients:

 CD4 count less than 200 cells/mL: obtain baseline ophthalmologic examination, start
Pneumocystis jiroveci pneumonia (PCP) prophylaxis with
trimethoprim-sulfamethoxazole (TMP-SMX), 1 double-strength tablet daily (preferred regimen);
or dapsone, 100 mg orally once daily (check baseline G6PD); or atovaquone, 1500 mg daily.

 CD4 count less than 100 cells/mL: if toxoplasma IgG positive, start either TMP/SMX double-
strength daily or dapsone, 50 mg daily, and pyrimethamine, 50 mg once weekly, with folinic
acid, 25 mg once weekly.

 CD4 count less than 50 cells/mL: ophthalmologist examination every 3 months, prophylaxis
against Mycobacterium avium complex (MAC) with azithromycin, 1200 mg weekly, or
clarithromycin, 500 mg orally twice daily.

From: Runge MS and Greganti MA. Netter's Internal Medicine 2nd Ed. Saunders, 2008

Marc Imhotep Cray, M.D. 48
HIV Thumbnail
Acute human immunodeficiency virus (HIV) infection is characterized by
many nonspecific symptoms and can resemble infectious mononucleosis

The HIV screening test is enzyme-linked immunosorbent assay (ELISA)
Western blot is used as the confirmatory test

HIV, with gp120 and gp41, infects T cells that express CD4 and either CXCR4
or CCR5
 HIV can also infect phagocytic cells (e.g., macrophages, dendritic cells,
microglial cells). Microglia infected with HIV forms multinucleated giant
cells in the central nervous system (CNS)

Marc Imhotep Cray, M.D. 49
HIV Thumbnail (2)
 HIV reverse transcriptase is very error-prone, and thus, suboptimal highly
active antiretroviral therapy (HAART) compliance leads to rapid proliferation of
resistant strains

 HIV infection is said to have progressed to acquired immunodeficiency
syndrome (AIDS) when the CD4+ T cell count falls below 200 mcL or patient
presents with one of the AIDS-defining opportunistic infections/malignancies

 Pneumocystis jirovecii pneumonia is the most common significant
opportunistic infection in HIV patients and causes a diffuse symmetrical
interstitial [lung] infiltrate
 Trimethoprim-sulfamethoxazole (TMP-SMX) is treatment (and prophylaxis)
of choice
Marc Imhotep Cray, M.D. 50
CDC Classification Categories of HIV
Infection

CDC. Centers for Disease Control and Prevention: 1993 revised classification system and expanded surveillance
definition for AIDS among adolescents and adults. MMWR 41(RR-17):1, 1992.

Marc Imhotep Cray, M.D. 51
Conditions Included in 1993 AIDS* Surveillance Case Definition
 Candidiasis of bronchi, trachea, lungs, or esophagus  Leukoencephalopathy, progressive multifocal
 Cervical cancer, invasive  Lymphoma, Burkitt’s (or equivalent form),
 Coccidioidomycosis, disseminated or  immunoblastic (or equivalent form), or primary
extrapulmonary of brain
 Cryptococcosis, extrapulmonary  Mycobacterium avium complex or M. kansasii,
 Cryptosporidiosis, chronic intestinal (>1 month  disseminated or extrapulmonary
duration)  Mycobacterium tuberculosis, pulmonary or
 Cytomegalovirus disease (other than liver, spleen, or  extrapulmonary
nodes; including cytomegalovirus retinitis with loss  Mycobacterium, other species or unidentified
of vision) species,
 Encephalopathy, HIV related  disseminated or extrapulmonary
 Herpes simplex: chronic ulcers (>1 month duration)  Pneumocystis carinii
or bronchitis, pneumonitis, or esophagitis  Pneumonia, recurrent
 Histoplasmosis, disseminated or extrapulmonary  Salmonella septicemia, recurrent
 Isosporiasis, chronic intestinal (>1 month duration)  Toxoplasmosis of brain
 Kaposi’s sarcoma  Wasting syndrome due to HIV
*Patients infected with HIV and who have a CD4+ T-cell count <200 or CD4+ percent <14% are classified as having AIDS.
Adapted from 1993 Revised classification system for HIV infection and expanded surveillance case definition for AIDS among
52
adolescents and adults. MMWR Recomm Rep 41(RR-17):1-19, 1992.
Select HIV Infection and AIDS related
Gross and Microscopic
Pathology Plates and Radiographs

Marc Imhotep Cray, M.D. 53
Pneumocystis pneumonia,
microscopic
 Granular pink alveolar exudate ( )
of Pneumocystis jiroveci
pneumonia (left panel) consists of
edema fluid, protein, Pneumocystis
organisms, and dead inflammatory
cells
 Mononuclear cells infiltrate
interstitium
 Gomori methenamine silver (GMS)
stain on bronchoalveolar lavage
fluid (right panel) shows 4- to 8-μm
dark cyst walls of organisms
appearing as crushed Ping-Pong
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. 2015
balls

Marc Imhotep Cray, M.D. 54
Pneumocystis pneumonia, CXR
 Chest x-ray show a diffuse ground-
glass pattern throughout lungs
 Term ground-glass refers to edge of
a microscope slide that can be
written on with pencil, and it means
that although area remains
transparent, one cannot see detail
through it
 This pattern is characteristic of
pneumocystis pneumonia,
commonly known as PCP

Studdiford, JS and Tully AS. USMLE Images for the Boards: Philadelphia. Saunders ,2013

Marc Imhotep Cray, M.D. 55
Progressive multifocal
leukoencephalopathy,
microscopic
 PML lesions have perivascular
monocyte infiltrates, astrocytosis with
bizarre or enlarged astrocytes (with
occasional mitotic figures), and central
lipid-laden macrophages
 Virus preferentially infects
oligodendrocytes in white matter,
leading to demyelination
 Shown here at periphery of lesions are
large “ballooned” oligodendrocytes
infected with JC polyoma virus that Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. 2015
have enlarged dark pink, ground-glass
nuclei (arrowhead) containing viral
antigen
Marc Imhotep Cray, M.D. 56
Progressive multifocal
leukoencephalopathy, MRI
 PML occurs in immunocompromised
patients, such as those with AIDS,
from reactivation of JC polyomavirus
infection
 Shown here are areas of markedly
increased signal intensity in left
hemisphere (right panel) with T2
weighting, fat saturation
 Extensive white matter involvement
is subtle with T1 weighting,
postgadolinium (left panel) Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. 2015
 multifocal lesions may also involve
cerebellum

Marc Imhotep Cray, M.D. 57
Kaposi sarcoma, gross
 Epidemic form of KS seen with AIDS usually
appears in men who have sex with men and is
rare in other groups at risk for HIV infection
 Risk factor for KS is infection with human
herpesvirus 8 (HHV-8), known as the Kaposi
sarcoma–associated herpesvirus (KSHV),
which can be sexually transmitted
o seroprevalence of HHV-8 is 5% to 10% of
general population, but 20% to 70% in
men who have sex with men
 Lesions can start as small reddish to red-
purple plaques or patches on one or more
areas of skin
 Over time lesions may become nodular,
larger, and more numerous
 In patients who test positive for HIV, KS is
diagnostic of AIDS
 Use of antiretroviral therapy markedly
decreases incidence of KS Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. 2015

Marc Imhotep Cray, M.D. 58
Mycobacterium avium complex
infection, gross
 Seen here in this cross-section of
spleen are numerous small white
nodules representing ill-formed
granulomas
 This patient had disseminated
Mycobacterium avium complex
(MAC) infection, and organs of
mononuclear phagocyte system
are often involved
 MAC infection is most likely to
occur in immunocompromised
persons, such as those with HIV
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. 2015
infection with CD4 count< 50

Marc Imhotep Cray, M.D. 59
Cytomegalovirus pneumonia,
microscopic
 Note very large cells that have large
violet intranuclear inclusions
surrounded by a small clear halo
 This Cowdry type A bodies are
typically referred to as “owl’s
eyes” due to their microscopic
appearance
 Basophilic stippling (arrow ) can be
seen in cytoplasm of these
cytomegalic cells
 Endothelial and epithelial cells can
become infected
 Though infection may begin in lungs,
dissemination to other organs is Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. 2015
common=CMV retinitis

Marc Imhotep Cray, M.D. 60
HIV encephalitis, microscopic
 HIV infection often involves brain
through macrophages that are carried
there from reservoirs of infection within
lymphoid tissues
 Shown here is an encephalitis with a
focal lesion (microglial nodule) showing
perivascular multinucleated cells
(arrow), which can be infected by HIV
 There are few lymphocytes because of
markedly reduced number of CD4
lymphocytes with progression of HIV
infection
 Brain injury is potentiated by microglial
activation and cytokine release
 Encephalitis can lead to progressive
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. 2015
loss of cognitive and motor function,
termed HIV-associated dementia
 Aseptic meningitis may also occur with
acute HIV infection
Marc Imhotep Cray, M.D. 61
Primary central nervous system
lymphoma, MRI
 There is one large periventricular mass (L
arrow ), with smaller masses, showing
increased signal intensity with
gadolinium enhancement
 Areas of lower signal intensity (R arrow )
represent tumor necrosis, and there is
diminished intensity of surrounding
brain from edema
 These lesions often involve deep gray
matter, but also white matter and cortex
 Periventricular spread is common
 They often have extensive central
necrosis Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. 2015
 Most are aggressive diffuse large cell B-
cell lymphomas arising with Epstein-Barr
virus infection in immunocompromised
persons those with HIV infection 62
Cryptosporidiosis, microscopic
 Small round pale blue objects (arrow ) at
luminal border or within a vacuole in
peripheral enterocyte cytoplasm are
Cryptosporidium parvum organisms
 Organisms rarely invade or disseminate
 There is no inflammation, necrosis, or
hemorrhage
 This infection most frequently affects
immunocompromised patients,
particularly those with AIDS
 Immunocompetent patients may develop
only a mild watery diarrhea; but with
diminished cell-mediated immunity,
cryptosporidiosis produces a copious
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. 2015
watery diarrhea
 Diagnosis is typically made by
examination of a stool specimen, and
organisms can be highlighted with an
acid-fast stain
Marc Imhotep Cray, M.D. 63
Cryptococcal meningitis,
gross and microscopic
The coronal section shows a thick
mucoid exudate within the
subarachnoid space ( ), ventricles ( ),
and brain parenchyma ( ) in an
immunocompromised patient with
Cryptococcus
neoformans meningitis. Perivascular
collections of the organisms can cause
small cystic spaces
within the brain. An India ink stain of
CSF (right panel) reveals the thick, clear
capsule of these organisms Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. 2015
surrounding these yeasts. The CSF may
have a mild to moderate leukocytosis,
elevated protein, and decreased
glucose.

Marc Imhotep Cray, M.D. 64
Toxoplasma encephalitis, CT image
 Toxoplasma gondii infection can be congenital
in neonates or an opportunistic infection of
immunocompromised adults
 This CT scan shows several ring-enhancing
lesions (arrowhead) with darker areas of
surrounding edema that are typical of
toxoplasmosis producing multiple abscesses in
adults
 Vascularity in organizing wall of an abscess
leads to the observed bright ring
enhancement with CT and MRI

Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. 2015

Marc Imhotep Cray, M.D. 65
Toxoplasmosis, microscopic
 T. gondii infection can result in
formation of pseudocysts, which
occur within an infected cell, with
cell membrane forming the cyst wall
 Pseudocysts ( ) are visible in left
panel within the cerebrum in a
microglial nodule of a patient with
AIDS
 In right panel immunohistochemical
staining with antibody to T. gondii
highlights brown bradyzoites within
the pseudocyst and adjacent free
tachyzoites ( )
 Organisms become progressively
harder to detect as abscessing
lesions become more chronic and
organized
Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. 2015

Marc Imhotep Cray, M.D. 66
HIV Infection Summary
What is HIV?
 HIV is an RNA retrovirus of the lentivirus genus
 This virus causes acquired immunodeficiency syndrome (AIDS)
Causes
 There are two types of HIV:
1. HIV-1:
o Type M: A-J prevalent in Europe, America, Australia and
sub-Saharan Africa Type
o Type O: mainly in Cameroon
2. HIV-2: predominantly confined to West Africa

Marc Imhotep Cray, M.D. 67
HIV Infection Summary cont.
Transmission
 Unprotected sexual intercourse
 Shared contaminated needles
 Contaminated blood transfusions
 Vertical transmission from mother to child

Virus crosses placenta and is transmitted through breast milk

Marc Imhotep Cray, M.D. 68
HIV Infection Summary cont.

 Genes required for viral replication
Remember PEG
 pol : encodes reverse transcriptase and integrase
 env : encodes envelope proteins, e.g. gp120
 gag : encodes viral structural proteins

Marc Imhotep Cray, M.D. 69
HIV Infection Summary cont.
Infection process
 gp120 antigen on HIV binds to CD4+ receptors on T cell This
process produces a conformational change and need to bind to a co-
receptor: CCR5 or CXCR4
 gp41 binds to co-receptor This binding causes ‘six-helix bundle
formation’ and fusion of the viral and host membranes
 Disintegration of viral capsid occurs causing viral RNA to be released
into human cell
 Double-stranded RNA is produced and this process is catalyzed by
viral reverse transcriptase
 Double-stranded RNA is integrated into host DNA using integrase
enzyme
 Host cell now manufactures new virions by long terminal repeat
Marc Imhotep Cray, M.D. 70
HIV Infection Summary cont.
Investigations
 Bloods: CBC, Electrolytes, BUN/Cr LFTs, lipids, glucose
 HIV specific:
o Enzyme-linked immunosorbent assay (ELISA)
o Western blot test
o Immunofluorescence assay (IFA)
o Nucleic acid testing
 Virology screen: HIV antibody, HIV viral load, HIV genotype,
hepatitis serology, cytomegalovirus (CMV) antibody, STIs
screen
 Other infection, e.g. tuberculosis if indicated
Marc Imhotep Cray, M.D. 71
HIV Infection Summary cont.
 Complications
 Increased risk of opportunistic infections:
o Toxoplasmosis
o CMV, e.g. retinitis
o Pneumocystis jiroveci pneumonia
o Cryptococcal meningitis
o Mycobacterium avium complex
o Candida
o Aspergillosis
 Increased risk of malignancies:
o Kaposi’s sarcoma
o Non-Hodgkin’s lymphoma
o Cervical cancer
o Anal cancer
Marc Imhotep Cray, M.D. 72
HIV Infection Summary cont.
 Treatment
 Conservative: patient education including transmission reduction advice,
Contact tracing, Psychological support
 Medical: highly active antiretroviral therapy (HAART): either
1. 2 × NRTIs combined with 1 × NNRTI or
2. 2 × NRTIs combined with 1 × PIs or
3. 1 × II:
o Nucleoside reverse transcriptase inhibitor (NRTI),e.g. zidovudine
o Non-nucleoside reverse transcriptase inhibitor (NNRTI), e.g.
nevirapine
o Protease inhibitor (PI), e.g. indinavir
o Integrase inhibitor (II), e.g. raltegravir
Marc Imhotep Cray, M.D. 73
THE END

74
Sources and further study:
Sources:
 Damjanov I, Pathology Secrets 3rd ed. Philadelphia: Mosby, 2009
 Diseases of the Immune System, Ch. 6. . Immunodeficiency Syndromes, Acquired Immunodeficiency
Syndrome (AIDS). Pgs.441-463 In: Kumar V and Abbas AK. Robbins and Cotran Pathologic Basis of
Disease 8th ed. Philadelphia: Saunders, 2014
 Kishiyama JL. Ch. 3 Disorders of the Immune System, AIDS Pgs. 53-57 In: Hammer GD and McPhee JS.
Eds. Pathophysiology of Disease : An Introduction to Clinical Medicine, 7th Ed. New York: McGraw-Hill
Education, 2014
 Longo DL, Fauci AS, Kasper DL, et al (editors). Harrison’s Principles of Internal Medicine, 18th ed.
McGraw-Hill, 2012
 Rubin R and Strayer DS Eds. Rubin’s Pathology: Clinicopathologic Foundations of Medicine, 6th Ed.
Baltimore: Lippincott Williams & Wilkins, 2012
 Klatt EC. Robbins and Cotran Atlas of Pathology, 3rd Ed. Philadelphia: Saunders, 2015
 Runge MS and Greganti MA. Netter's Internal Medicine 2nd Ed. Saunders, 2008
 Studdiford, JS and Tully AS. USMLE Images for the Boards: Philadelphia. Saunders, 2013
eLearning (IVMS Cloud)
 Infectious Disease
 Microbial biology & Immune System
 Rural Medicine Global Health (Focus on Ethiopia)
Marc Imhotep Cray, M.D. 75