Page 509 - Medicine and Surgery

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Chapter 12: HIV 505

abnormalities or cranial neuropathy. CT is used for classified as long-term non-progressors with normal
diagnosis. Lymphomas are often refractory to radio- CD4 counts and low viral load in the absence of treat-
therapy and chemotherapy. ment. Prognosis has been dramatically improved by
Pneumocystis jirovecii and Kaposi’s sarcoma as- combination antiretroviral therapy, and life expectancy

sociated with HIV are covered separately (see is likely to be more than doubled by this treatment.
below).

Kaposi’s sarcoma
Investigations
The detection of IgG antibody against envelope compo- Definition
nents of the virus is the most commonly used diagnostic Amulti-focal disease caused malignant by proliferation
test and PCR can be used to detect the virus. The disease of vascular endothelial cells.
is followed using quantitative PCR to determine the viral
load, and by the CD4 T cell count.
Aetiology/pathophysiology
Kaposi’s sarcoma in AIDS patients is particularly com-
Management mon in sexually transmitted HIV suggesting a sexually
At present, there is no consensus on whether patients transmitted cofactor such as human herpes virus 8. Ka-
withprimaryHIVinfectionshouldbetreated.Antiretro- posi’s sarcoma affects the skin, lung, lymphatic system
virals are only of proven benefit in advanced symp- and gastrointestinal system.
tomatic disease. In general treatment is commenced if
the patient is symptomatic, there is a rapidly falling CD4
Clinical features
count or a high viral load. Three classes of drugs are
Skin lesions occur most commonly on the lower limbs
available:
and appear in various colours from pale pink, through
Nucleoside-analogue reverse transcriptase inhibitors

violet to dark brown due to their vascularity. They may
such as zidovudine, didanosine, zalcitabine and
appear as plaques especially on the soles of the feet or
lamivudine.
dome shaped firm papules, which may ulcerate. Gas-
Non-nucleoside reverse transcriptase inhibitors such

trointestinal Kaposi’s sarcoma is usually asymptomatic
as nevirapine.
but may cause perforation, obstruction, haemorrhage,
Protease inhibitors such as ritonavir, indinavir.

jaundice from biliary obstruction, or protein losing en-
In general two nucleoside-analogue reverse transcrip-
teropathy due to mesenteric lymphatic obstruction. Dis-
tase inhibitors with one drug from either of the other
semination to the lungs and brain may occur.
two classes are used as first line treatment. Treatment
is tailored according to compliance, side effects and the
response to treatment. Investigations
Aclinical diagnosis, however biopsy reveals endothe-
Prevention strategies include safer sexual practice (re-
lial lined spaces interspersed by proliferating spindle
ducing the number of sexual partners, use of barrier
cells.
contraception),needleexchangeprogrammes,screening
of donor blood, semen and organs. Strategies to reduce
vertical transmission include screening, caesarean deliv- Management
ery, maternal and neonatal anti-retroviral treatment and Localisedorcutaneouslesionsmayrespondtoradiother-
avoidanceofbreast-feeding.Health-careworkersalsore- apy. Dissemination or visceral lesions require systemic
quire education, careful disposal of sharps and prophy- chemotherapy.
laxis following needle stick injuries.
Prognosis
Prognosis Cutaneous Kaposi’s sarcoma may be non-aggressive,
Untreated the life expectancy of an HIV infected indi- however visceral and disseminated disease can be serious
vidual is approximately 10 years. A few individuals are and life threatening.