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ORIGINAL ARTICLE |
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| Year : 2003 | Volume
: 57
| Issue : 1 | Page : 16-21 |
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Spectrum of opportunistic infections in AIDS cases.
A Singh, I Bairy, PG Shivananda
Dept. of Microbiology, Kasturba Medical College, Manipal 576 119,
| Date of Acceptance | 10-Sep-2002 |
Correspondence Address:
A Singh
Dept. of Microbiology, Kasturba Medical College, Manipal 576 119
PMID: 14514281
Human Immunodeficiency viruses are the initial causative agents in AIDS, but most of the morbidity and mortality in AIDS cases result from opportunistic infections, Identification of such pathogen is very important for clinicians and health planners to tackle the AIDS epidemic in more effective manner. The present study describes the clinical and laboratory profile of 100 AIDS causes who presented to a referral hospital. Oral candidiasis (59.00%) was found to be the most common opportunistic infection, followed by tuberculosis (56.00%), Cryptosporidium infection (47.00%) and Pneumocystis carinii (7.00%). Presence of oral candidiasis and weight loss is highly predictive of low DC4 count and can be considered as a marker of HIV disease progression. The patients coinfected with HIV and tuberculosis are also on rise. Recognition of dual infection and taking adequate steps to deal with this epidemic is needed. As Cryptosporidium infection was detected in large number, provision of safe drinking water and maintaining good hygiene is important for prevention. Early diagnosis of opportunistic infection and prompt treatment, delays the progression towards AIDS. 91.00% of patients were infected with HIV1 and 4.00% had HIV2 infection and 5.00% were dully infected. 87.00% of patients were males and 13.00% were belonging to 21-40 years of age. Majority of them were belonging to lower socioeconomic status and heterosexual route of transmission was the commonest mode of spread.
Keywords: AIDS-Related Opportunistic Infections, epidemiology,microbiology,Adult, Female, Human, India, epidemiology,Male,
How to cite this article:
Singh A, Bairy I, Shivananda P G. Spectrum of opportunistic infections in AIDS cases. Indian J Med Sci 2003;57:16-21 |
The emergence and pandemic spread of AIDS constitute the greatest challenge to public health in modern time. The first case of AIDS in India was reported in 1986. Now India is the country with the second largest population of HIV infected individuals. With the changing scenario of the AIDS epidemic, a host of opportunistic infections add to the present endemic state of the some already existing infections like tuberculosis.[1] In 1998 HIV infection or AIDS was the fourth leading cause of death worldwide, resulting in an estimated 2.3 million deaths. As on December 2001, In Karnataka, a total of 10833 H IV infected persons and 1354 AIDS cases were reported to NACO.[2]
HIV infection leads to AIDS and major cause of morbidity and mortality of such patients are opportunistic infections.[3] Many organisms responsible for opportunistic infections in such patients mimic similar clinical presentation. The type of pathogen responsible for morbidity and mortality vary from region to region. The identification of such pathogen is very important to manage the case. Hence the present study was carried out to find out the most common opportunistic pathogen and different opportunistic pathogens infecting HIV seropositive patients admitted to Kasturba Hospital, Manipal.
| ¤ Material and methods | |  |
A total of 100 HIV seropositive patients admitted to Kasturba Hospital, Manipal during June 1999 to March 2001 were investigated for various opportunistic pathogens. Their HIV status was confirmed by HIV ELISA and HIV Spot test.
Various samples e.g.: sputum, oral swab, blood, stool, urine, cerebrospinal fluid (CSF), lymph node aspirate were collected as per symptoms and clinical presentations under universal aseptic precautions in suitable sterile containers. Specimens were stained using appropriate stains eg.: Gram, Giemsa, Trichrome, Ziehl - Neelsen, Kinyons staining, Silver methanamine and examined under microscope. Stool sample and sputum samples were stained after concentration technic. Direct saline and iodine mounts were prepared for stool sample and screened under microscope for helminthic eggs, larvae, protozoan cysts, tropozoits, pus cells and possible fungal elements. CSF samples were examined for Cryptococcus by Indian ink wet mount. Appropriate media like Blood agar, MacConkey agar, Chocolate agar, Sabourauds Dextrose agar and Lowenstein Jensen were used for isolation of pathogens. The pathogens isolated were further identified following standard protocol.
The sera were examined for Syphilis (VDRL test, TPHA test), Hepatitis B (Bio ELISA - HbsAg), Toxoplasma (IgM Capture Elisa), HSV 1 and 2 (IgM - Equip - R Glaxo), CMV (IgM Capture ELISA - Equip - R Glaxo)
| ¤ Results | | |
A total of 100 HIV seropositive patients were included in the study group. The age and sex distribution of the cases is shown in the [Table - 1]. All the patients presented with more than one symptom. As shown in [Table - 2], 59 (59.00%) patients had oral thrush and six had gastrointestinal candidiasis. One female patient had vaginal candidiasis. Candida albicans was the pathogen isolated. A total of 56 (56.00%) patients had tuberculosis among 100 HIV seropositive cases. 35 of them had pulmonary tuberculosis and 21 had extra pulmonary tuberculosis. Cryptosporidium was demonstrated in 43 (43.00%) patients and Pneumocystis carinii was demonstrated in 7 (7.00%) patients. Other infections are shown in [Table - 2].
| ¤ Discussion | | |
Although the Human Immunodeficiency Viruses are the initial causative agents in AIDS, most of the morbidity and mortality seen in the case of AIDS patient results from the opportunistic infections which take advantage of the lowered cellular and humoral defences of the patient. A wide variety of these infections are encountered in the AIDS population, including bacteria, fungi, viruses and protozoa. Very often, these represent not new infections but the reactivation of old infection.[4]
In the present study the patients presented with more than one symptom, the common being asthenia, fatigue and malaise loss of weight, fever, chronic cough, loss of appetite and diarrhoea.
Out of 100 HIV positive screened 87 (87.00%) were male and 13 (13.00%) were females. 54.00% (54/100) cases were from the age group of 31-40 years and 38.00% (38/100) were belonging to 21-30 years, thus 92/100 (92.00%) were belonging to 21-40 years of age which is the sexually active age group. Most of the patients were belonging to lower socio economic status, staying away from family, went in search of job to metropolitan cities mainly to Mumbai. They were working as hotel waiters, taxi drivers, panwallahs and mechanics. They returned when they were not able to work anymore and while investigating for the presenting symptoms were found to be HIV seropositive. Heterosexual route of transmission was the commonest mode of spread.
Oral candidiasis was the most common (59.00%) opportunistic infection and our finding is similar to the report of NACO[5] and T K Giri et al.[5] But Kaur et a1[6] from Vellore have reported oral candidiasis as the second most common infection in AIDS patients. Ayyagari et a1[7] have reported very low incidence of candidiasis (27.7%).
Presence of oral candidiasis and weight loss is the marker of HIV disease progression. Hence regular examination of oral cavity is important.
Mycobacterium tuberculosis was the commonest isolate reported in few studies from India.[6],[7],[8] But we observed it as the second most common pathogen (56.00%) as NACO.[4] Pulmonary tuberculosis was observed in 35.00% and extra pulmonary tuberculosis in 21.00% of cases. HIV infection is a strong risk factor for the active tuberculosis in persons with latent M. tuberculosis infection. The risk of active tuberculosis in HIV seropositive persons is 14% over 2 years - contrasting strikingly with the estimated 10% lifetime risk in H IV negative persons with latent tuberculosis infection.
Tuberculosis is endemic in India and is the common cause of death in AIDS patients. Its prevalence is reported to be increasing in patients with HIV infection. Among HIV infected patients with advanced immunodeficiency and pulmonary tuberculosis, cavitary lisions are relatively rare and radiographic infiltrates can not be used to reliably distinguish between tuberculosis and pulmonary pathogens. Thus the prompt diagnosis of pulmonary tuberculosis in persons infected with HIV requires high index of suspicion and access to specialized laboratory technics such as microscopy, sputum smears and mycobacterial cultures.
Cryptosporidium infection was observed in 43 (43.00%) cases. Low socioeconomic status, poor hygiene, unavailability of safe drinking water and frequent contact with livestock may be responsible for the high percentage of cryptosporidiosis. Provision of safe drinking water and maintaining good hygiene is important in prevention.
Seven (7.00%) patients had Pneumocystis carinii pneumonia. Even though pneumonia due to P carinii is one of the most common opportunistic infection in AIDS patients, the frequency with which it is recognised among HIV patients in tropical and developing countries is generally much lower than that in industrialised nations.[9] Nowadays the incidence has decreased in part due to prophylaxis. It has often been the AIDS defining illness, with upto 80% of patients being prior to the use of prophylactic therapy.
Cryptococcus meningitis was diagnosed in 7(7.00%) of cases. (6 males and 1 female). All were from the age group of 31 - 40 years. Indian reports shows the incidence of cryptococcal infection of 6 -
8%,[4],[7],[11] whereas it is about 5 - 11% in USA, 33% in Africa and 28.5% in Thailand.[12]
Out of 100 cases 4 showed high titres of IgM for Toxoplasma. All were males from the age group of 31 - 40 years. Although serological test here is not diagnostic, presence of specific IgM supports diagnosis.[7] Compared to NACO report which shows the incidence of 12.80% the incidence in our study is low.
Emphasis on specific measures to prevent opportunistic infections is important because of limitations of highly active antiretroviral therapy. Although many patients benefit from antiretroviral therapy, not all patients are willing to take it, many patients cannot tolerate or adhere to the complex drug regimes that constitute this therapy, and immunity cannot be restored to a level that substantially reduces the risk of opportunistic infection. With better knowledge and diagnosis of the opportunistic infections in HIV patients, clinicians and health planners can tackle the AIDS epidemic in a more effective manner. Specific. antimicrobial prophylaxis by itself or in conjunction with antiretroviral therapy, can reduce the substantial morbidity and mortality caused by opportunistic infections in patients with HIV infections. Early diagnosis of opportunistic infections and prompt treatment definitely contributes to increased life expectancy among infected patients delaying the progression to AIDS.
| ¤ References | | |
| 1. | Misra SN, Sengupta D, Satpathy K. AIDS in India: Recent trends in opportunistic infections. South East-Asian J Trop Med Public Health 1998;29:373-6.  |
| 2. | Monthly report of HIV/AIDS for the month of December 2001, Karnataka State AIDS Prevention Society, 2002. |
| 3. | Gradon JD, Timpone JG, Schnittman SM. Emergence of unusual opportunistic pathogensin AIDS A review. Clin Infect Dis 1992;15:134-57. [PUBMED] |
| 4. | National guidelines for clinical management of HIV/AIDS. National AIDS Control Organisation, Ministry of Health and Family Welfare. New Delhi: Government of India; 2000. p. 17-52. |
| 5. | Giri TK, Pande I, Mishra NM, et al. Spectrum of clinical and laboratory characteristics of HIV infection in Northern India J Com Dis 1995;27:131-41. [PUBMED] |
| 6. | Kaur A, Babu PG, Jacob M, et al. Clinical and laboratory profile of AIDS in India. J Acquir Defic Synd 1992;5:883-9. [PUBMED] |
| 7. | Ayyagari A, Sharma AK, Prasad KN, et al. Spectrum of Opportunistic infections in HIV infected cases in a Tertiary care Hospital. Indian J Med Microbiol 1999;17:78-80. |
| 8. | Kumaraswamy N, Solomon S. Spectrum of opportunistic infections among AIDS patient in Tamil Nadu, India Int J STD AIDS 1995;6:447-9. |
| 9. | Russian DA, Kovacs JA. Pneumocystis carinii in Africa. An emerging pathogen? Lancet 1995;346:1242-3. [PUBMED] |
| 10. | Robert W, Pinner, et al. Prospects of preventing Cryptococcosis in persons infected with HIV. Clinical Infectious Diseases 1995;21:103-7. |
| 11. | Lanjewar DN, Jain PP, Shetty CR. Profile of CNS pathology in patients with AIDS: An autopsy study from India. AIDS 1990;12:309-313. |
| 12. | Satishchandra NA, Gowri D, et al. Profile of neurological disorders associated with HIV/ AIDS from Bangalore, South India (1986-96). Indian J Med Res 2000;111:14-23. |
Tables
[Table - 1], [Table - 2]
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