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HIV-Related Opportunistic Infections

Spectrum of infections in advanced HIV/AIDS triggered by CD4 depletion, requiring CD4-stratified prophylaxis and prompt empirical therapy.

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

References (5)

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Internal Medicine department. Book Appointment →

What is HIV-Related Opportunistic Infections?

Opportunistic infections (OIs) in HIV are infections that occur with greater frequency or severity due to immunosuppression caused by progressive CD4+ T-cell depletion. The spectrum of disease is largely determined by absolute CD4 count: bacterial pneumonias and tuberculosis throughout, candidiasis at CD4 < 500, Pneumocystis jirovecii (PJP) at CD4 < 200, toxoplasmosis at CD4 < 100, and cytomegalovirus (CMV), Mycobacterium avium complex (MAC), and cryptococcosis at CD4 < 50.

Antiretroviral therapy (ART) has dramatically reduced the incidence and mortality of OIs but they remain common in newly diagnosed late-presenters, treatment failures, and persons with poor adherence. Immune reconstitution inflammatory syndrome (IRIS) may occur with rapid CD4 recovery and complicate management of mycobacterial, cryptococcal, and viral infections.

Management combines prophylaxis (TMP-SMX for PJP and toxoplasmosis at CD4 < 200, azithromycin for MAC at CD4 < 50), early diagnostic workup (LP for cryptococcal antigen, CMV PCR, mycobacterial cultures), targeted antimicrobial therapy, and timely initiation of ART (immediate in most OIs except cryptococcal meningitis and tuberculous meningitis where 2–10 week delay is recommended).

Symptoms

PJP: subacute dyspnea, dry cough, hypoxia, ground-glass opacities
Toxoplasmosis: focal neurologic deficits, seizures, ring-enhancing brain lesions
Cryptococcal meningitis: headache, fever, altered mentation, raised ICP
CMV retinitis: floaters, vision loss, hemorrhagic retinitis
CMV colitis: abdominal pain, diarrhea, weight loss
MAC: fever, night sweats, weight loss, anemia, hepatosplenomegaly
Esophageal candidiasis: odynophagia, dysphagia
Tuberculosis: cough, fever, weight loss, may be extrapulmonary
PML: progressive focal neurologic deficits, JC virus reactivation
Histoplasmosis/coccidioidomycosis: pulmonary, disseminated symptoms
Bacterial pneumonia (Streptococcus pneumoniae)
Recurrent salmonellosis
Cryptosporidiosis: chronic diarrhea
Microsporidiosis: chronic diarrhea, biliary disease
Kaposi sarcoma: HHV-8 related skin/visceral lesions

Risk Factors

CD4 count below 200 cells/mm3
CD4 below 50 (severe risk for CMV, MAC, cryptococcosis)
Poor ART adherence or treatment failure
Late HIV diagnosis (low CD4 nadir)
Lack of OI prophylaxis
Co-infection with hepatitis B/C
Active substance use
Homelessness, food insecurity
Travel or residence in endemic areas (TB, histoplasmosis, coccidioidomycosis, leishmaniasis)
Cat exposure (toxoplasmosis)
Pigeon, soil exposure (cryptococcosis)
Prior or recent immunosuppression (steroids)
Pregnancy with poor ART access
Children with vertical HIV
Resource-limited settings

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • HIV patient with new fever, cough, dyspnea
  • Headache, neck stiffness, altered mentation in HIV patient
  • Visual symptoms (floaters, decreased acuity) in advanced HIV
  • Chronic diarrhea, weight loss, oral thrush
  • Focal neurologic deficits or seizures
  • Skin lesions suggestive of Kaposi sarcoma
  • Night sweats, persistent fever
  • CD4 below 200 without prophylaxis
  • Treatment failure or detectable viral load
  • Newly diagnosed HIV with constitutional symptoms

Treatment Methods

01
CD4 count, HIV viral load, baseline labs (CBC, LFTs, renal function)
02
PJP: TMP-SMX 15-20 mg/kg/day TMP component PO/IV for 21 days; adjunctive prednisone if PaO2 < 70 mmHg
03
Toxoplasmosis: pyrimethamine plus sulfadiazine plus leucovorin or TMP-SMX for 6 weeks induction, lifelong suppression
04
Cryptococcal meningitis: liposomal amphotericin B plus flucytosine for 2 weeks induction, fluconazole consolidation 8 weeks, maintenance until CD4 > 200 for 6 months
05
CMV retinitis: oral valganciclovir 900 mg BID for 21 days induction then 900 mg daily maintenance; intravitreal injection for sight-threatening lesions
06
MAC: azithromycin or clarithromycin plus ethambutol; rifabutin in severe disease; lifelong if no immune reconstitution
07
Tuberculosis: standard 4-drug therapy with attention to drug interactions; ART start within 2 weeks if CD4 < 50
08
Esophageal candidiasis: fluconazole 200 mg/day for 14-21 days
09
Cryptosporidiosis: nitazoxanide; ART is mainstay
10
Histoplasmosis: liposomal amphotericin B then itraconazole
11
Prophylaxis: TMP-SMX for CD4 < 200 (PJP, toxo); azithromycin for CD4 < 50 (MAC); discontinue when CD4 > 200 for 3-6 months
12
ART initiation within 2 weeks of OI treatment except cryptococcal/TB meningitis (4-10 weeks)
13
Monitor for IRIS during ART initiation
14
Vaccinations: pneumococcal, influenza, hepatitis B, HPV per HIV-specific schedules
15
Tuberculosis screening (IGRA or TST) at baseline and annually
16
Cervical and anal cancer screening due to HPV reactivation
17
Address adherence, mental health, substance use
18
Multidisciplinary HIV care with infectious disease specialist
19
Patient education on warning signs and prophylaxis adherence

Which Department to Visit?

You can visit our Enfeksiyon Hastalıkları department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.