Acquired Immunodeficiency Syndrome

Definition
AIDS (Acquired Immunodeficiency

Syndrome)
A recently recognized condition characterized by a defect in natural immunity against disease. Breakdown of this definition:
Acquired Immuno Deficiency Syndrome

Definition
Acquired
disease is not inherited or genetic but develops as result of a virus

Immuno
refers to the bodys immunologic system

Deficiency
indicates that the immune system is underfunctioning

Syndrome
resulting in a group of signs and symptoms that occur together

Epidemiology
WHO estimated that 2.5 million and 1 million children had AIDS and about 22 million people were infected with HIV worldwide AIDS was the leading cause of death among Americans 25 44 years old The ratio of men to women who are infected is estimated to be 6:1, but the number of infected women is growing faster than the number of infected men

Epidemiology
WHO Asia has the lowest number of cases 3,561 America has the highest 371,086 and in USA alone 47,051 are affected

Epidemiology

Epidemiology
Risk Groups: Homosexuals Intravenous drug users Bisexuals Blood transfusion Organ transplantation Dialysis recipients

Epidemiology
Risk Groups: Hemophiliacs People with heterosexual contact with partners who are infected with AIDS Transmission from mother to baby Heath care professionals & laboratory workers

Etiology
Etiologic Agent: HIV Subfamily: Lentivirus Family: Human retrovirus Retrovirus depends upon unique enzyme called Reverse Transcriptase (RNA directed DNA polymerase), to replicate with the host

Etiology
There are 4 recognized Human retrovirus Human T lymphotropic virus
HTLV-I HTLV-II

Human Immunodeficiency viruses

HIV-I HIV-II

Etiology
Human T lymphotropic virus
HTLV-I
which is associated with lymphoma.

HTLV-II
provirus in circulating cells of the monocyte / macrophage.

Etiology
Human Immunodeficiency viruses
HIV-I
classic AIDS virus much more closely related phylogenetically to the simian immunodeficiency virus (SIV) found most common type

HIV-II
has 40% nucleotide sequence homology with HIV-I

Etiology
Modes of Transmission: Horizontal
Sexual contact Exposure to infected blood or other blood products Intravenous drug users/needle sharing

Vertical
Peri-natally from the mother to the neonate

Etiology
Modes of Transmission: HIV has been isolated from blood, semen, vaginal secretions, saliva, tears, breast milk, cerebrospinal fluid, amniotic fluid & urine & is likely to be isolated from other body fluids, secretions & excretions.
However, epidemiologic evidence has implicated only blood, semen, vaginal secretions & possibly breast milk in transmission.

Etiology
Modes of Transmission: There is no evidence of transmission by causal contact through the use of shared food, towel, cups, razors, toothbrushes or even kissing.

Pathophysiology and Immunopathogenesis

Hallmark of HIV Disease: Profound Immunodeficiency (quantitative and qualitative decrease of CD4+ T-lymphocyte; normal is 700 1400/mL).

Pathophysiology and Immunopathogenesis

Pathophysiology and Immunopathogenesis

Clinical Manifestations
Acute HIV syndrome (approx. 50%

70%) Asymptomatic stage-Clinical Latency Early Symptomatic Disease (ARC or AIDS Related Complex) AIDS (Full Blown)

Clinical Manifestations
Acute HIV syndrome (approx. 50%

70%)
Symptoms usually persist for 1 2 wks & gradually subside as immune response to HIV. Opportunistic infections have been reported during this stage of infection, presumably as a result of the transient immunosuppression.

Clinical Manifestations
Acute HIV syndrome (approx. 50%

70%)
Typical clinical findings:
General

Lethargy/malaise Fever Weight loss/anorexia Pharyngitis Nausea/vomiting/diarrhea Lymphadenopathy Headache Retro-orbital pain Arthralgias / myalgias

Clinical Manifestations
Acute HIV syndrome (approx. 50%

70%)
Typical clinical findings:
Neuropathic
Meningitis Encephalitis Peripheral neuropathy Myelopathy

Dermatologic
Erythematous maculopapular rash Mucocutaneous ulceration

Clinical Manifestations
Asymptomatic stage-Clinical Latency The initial symptoms may be associated with the first manifestation of an opportunistic disease Experiences varying degrees of intermittent symptoms such as malaise, lethargy, weakness, anorexia, and persistent generalized lymphadenopathy High risk opportunistic & clinically apparent disease

Clinical Manifestations
Early Symptomatic Disease (ARC or

AIDS Related Complex)

Clinical characteristics
Generalized lymphadenopathy (>1cm) Oral lesions Reactivation herpes zoster or shingles (10-20%) Thrombocytopenia (3%; platelet 150,000)

Clinical Manifestations
Early Symptomatic Disease (ARC or

AIDS Related Complex)

Clinical characteristics
Generalized lymphadenopathy (>1cm)
Extra-inguinal sites; >3 months; idiopathic Earliest symptoms ff. Acute syndrome

Clinical Manifestations
Early Symptomatic Disease (ARC or

AIDS Related Complex)

Clinical characteristics
Oral lesions
Thrush White, cheesy exudate erythematous mucosa Soft palate are mostly affected Oral hairy leukoplakia Filamentous white lesion (lateral borders of the tongue) Aphthous ulcers of the posterior oropharynx Painful, interference swallowing

Clinical Manifestations
Early Symptomatic Disease (ARC or

AIDS Related Complex)

Clinical characteristics
Reactivation herpes zoster or shingles (10-20%)
1st clinical indication of immunodeficiency 5 years following primary infection

Thrombocytopenia (3%; platelet 150,000)

Bleeding gums, extremity petechiae, easy bruisability

Clinical Manifestations
AIDS (Full Blown) Opportunistic infection disease would set in:
Pneumocystis Carinii Pneumonia TB Kaposis Sarcoma Others

Complications
The complications of HIV-related infections

and neoplasms affect virtually every organ.

General approach to HIV-infected person with symptoms:
evaluate the organ system involved, aiming to diagnose treatable conditions rapidly.

Certain infections may occur at any CD4+ count, while others rarely occur unless the CD4+ lymphocyte count has dropped below a certain level.

Complications
The complications of HIV-related infections

and neoplasms affect virtually every organ.

Abnormal findings range from completely nonspecific to highly specific for HIV infection.

Complications
Gynecologic complications: Vaginal candidiasis Cervical dysplasia Neoplasia Pelvic inflammatory disease
HIV-related malignancies: Kaposis Sarcoma Non-Hodgkins carcinoma

Complications
Endocrinologic complication: Adrenal gland is the most commonly afflicted
Skin complications: Viral dermatitis Bacterial dermatitis Fungal dermatitis Neoplastic dermatitis Nonspecific dermatitis

Complications
Gastrointestinal complications: Candidal esophagitis Hepatic diseases Biliary diseases Enterocolitis Other disorders Gastropathy Malabsorption

Complications
CNS complications: Toxoplasmosis CNS lymphoma AIDS dementia complex Cryptococcal meningitis

Complications
Sinopulmonary complications: Pneumonia & other infectious pulmonary diseases Noninfectious pulmonary diseases Sinusitis
Oral lesions, retinitis, myopathy, and

rheumatologic manifestations Other systemic complaints

Diagnosis
Licensed tests for diagnosing HIV infection: Enzyme Linked Immunosorbent Assay (ELISA)
Standard screening test Extremely sensitive test Disadvantage: Low specificity

Western Blot Assay (WBA)

Most common confirmatory test

Diagnosis
Licensed tests for diagnosing HIV infection: If one cannot afford WBA, confirm results by repeating ELISA after 4 12 weeks (3 months) for seroconversion to occur.
If still (+) then indicative of (+) HIV infection.

Diagnosis

Diagnosis
Tests for assessing disease progression: CD4+ T-cell Count p24 Antigen Capture Assay
Simplest test

Plasma HIV RNA Assay

Most sensitive and reliable measurement of plasma viral load

CD4+ T-cell count & Plasma HIV RNA assay are the most accurate assessment for disease progression & time of death

Prognosis
From the time of seroconversion, 10-20% of

HIV-infected individuals will progress to AIDS in 3 6 years. Once the patient has constitutional symptoms, herpes zoster, thrush or a lowered CD4+ lymphocyte count, chances are >40% of progressing to AIDS after 3 years of follow-up and >50% after 5 years.

Prognosis
Prognosis can be modified by antiretroviral

therapy and general medical support.

Medical Management
Management is usually supportive because

there is no known cure for AIDS.

Pharmacologic Management
The corner stone of pharmacological

management of HIV infection is ANTIRETROVIRAL therapy.

Nucleoside Analog Reverse Transcriptase Inhibitors (NARTI) Protease Inhibitors Non-nucleoside Reverse Transcriptase Inhibitor

Pharmacologic Management
Nucleoside Analog Reverse Transcriptase

Inhibitors (NARTI):
Zidovudine (AZT) Zalcitabine (ddC) Lamivudine (3TC) Didanosine (ddl) Stavudine (d4T)

Pharmacologic Management
Protease Inhibitors: Saquinavir Ritonavir Indinavir
Non-nucleoside Reverse Transcriptase

Inhibitor:
Acvirapine

Pharmacologic Management
For acute exposure to the infected products

of an HIV-infected person, prophylaxis may be given. One may take these drugs simultaneously:
AZT (Zidovudine) at 200mg 3x/day Lamivudine 150mg 2x/day Indivar 800mg 3x/day These must be taken within 24 hours upon exposure preferably within the first 2 4 hrs. Then take CBC count and use CD4+ as a baseline and repeat the test every 2 wks.

Surgical Management
When surgery is planned, preparations for

postoperative rehab can be made in advance.

Orthotic and prosthetic appliances also can be planned in advance and prosthetic fitting can even take place in the operating room. The need for pretreatment interventions in the patient undergoing radiation therapy is equally important.

Surgical Management
When surgery is planned, preparations for

postoperative rehab can be made in advance.

The institution of a vigorous stretching program can help to prevent contractures and deformity that otherwise would occur as a result of radiation fibrosis. Training in skin care and the proper use of moisturizing creams can help to prevent breakdown or infection.

PT Examination
Assess the general condition of the patient.
Usual assessment of the patient includes: Pulmonary test UE and LE instability test ROM MMT Motor and sensory tests

PT Examination
Specific tests suitable for conditions /

complications present should be done and performed for confirmation.

PT Evaluation
Usual problems: Impaired mobility Difficulty with self-care Impaired cognition Uncontrolled pain

PT Evaluation
Check for deconditioning problems: Contracture Adhesions Atrophy LOM Weakness Instabilities Edema/swelling

PT Diagnosis
Most often, PT Diagnosis or Impression for

patients with this condition will fall under the specific conditions encountered.
Thus patients may be placed under multiple PT diagnostic classifications or labels.

PT Prognosis
PT Goals are directed to address the specific

problems in each case.

PT Interventions
Most important aspect of rehabilitation is to

keep the patient as mobile as possible to prevent the complications often associated with prolonged bed rest

PT Interventions
To improve function:
Gait and functional retraining Prevention of effects of deconditioning Use of adaptive equipment and strategies

PT Interventions
For impaired mobility, difficulty with selfcare, impaired cognition, and uncontrolled pain:
Therapeutic exercises Gait aids Bathroom and safety equipment Orthosis Pain management Whirlpool treatment Assistance especially in areas of stair climbing, ambulation, bowel management, and LE dressing

PT Interventions
For cancer pain and pain in patients with HIV:
Heat modalities
Caution: may increase circulation to the involved area, possibly increasing the potential for metastatic spread.

US over malignant tissues is contraindicated Therapeutic heat and cold are used on non-cancer patients TENS for reducing the dependence on opioid medications particularly in phantom pain, radiculopathy and incisional pain
Conventional high frequency setting is most effective

Thank You