ACQUIRED IMMUNODEFICIENCY SYNDROME

Definition
- AIDS (Acquired Immunodeficiency Syndrome) is a recently recognized condition characterized by a defect in natural
immunity against disease. Acquired refers to the fact that the disease is not inherited or genetic but develops as result of a
virus. Immuno refers to the body’s immunologic system and deficiency indicates that the immune system is
underfunctioning resulting in a group of signs and symptoms that occur together called syndrome.
Epidemiology
- The 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.
Asia has the lowest number of cases 3,561. America has the highest 371,086 and in USA alone 47,051 are affected.
- Risk Groups:
1. Homosexuals
2. Intravenous drug users
3. Bisexuals
4. Blood transfusion
5. Organ transplantation
6. Dialysis recipients
7. Hemophiliacs
8. People with heterosexual contact with partners who are infected with AIDS
9. Transmission from mother to baby
10. Heath care professionals & laboratory workers
Etiology
- Etiologic Agent: HIV
1. Subfamily: Lentivirus
2. Family: Human retrovirus
- Retrovirus – it depends upon unique enzyme called Reverse Transcriptase (RNA directed DNA polymerase), to
replicate with the host.
 There are 4 recognized Human retrovirus
a. Human T lymphotropic virus
HTLV-I = which is associated with lymphoma.
HTLV-II= provirus in circulating cells of the monocyte / macrophage.
b. 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
- Modes of Transmission:
 Horizontal
1. Sexual contact
2. Exposure to infected blood or other blood products
3. Intravenous drug users/needle sharing
 Vertical
1. Peri-natally from the mother to the neonate
 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.
 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).
VARIOUS STAGES OF HIV DISEASE TYPICAL COURSE OF AN HIV-INFECTED INDIVIDUAL
(PATHOGENIC EVENT)

‘PRIMARY INFECTION’
Virus enters ‘directly’ Virus enters ‘ locally’

Virus has been introduced to the dendritic cells then goes to the circulation

I. EARLY ASYMPTOMATIC STAGE CD4+ T-lymphocytes / helper cells

(>500/mL CD4+ T-lymphocytes) (1st target / destroyed)

Drain to the lymphoid organs

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Initial viremia

‘ACUTE HIV SYNDROME’

(3 – 6 weeks)
*HIV-specific immune response + trapping of folliculo-dendritic cells
Humeral immune response
- Increase in circulating antibodies (1 – 2 months)
Cellular immune response
- Increase of cytotoxic / suppressor cells + natural killer cells in the
body

Decreased viremia

‘ASYMPTOMATIC STAGE – CLINICAL LATENCY’

II. INTERMEDIATE STAGE
(~ 10 years)
(200-500/mL CD4+ T-lymphocytes)
*Increase of the virus in the lymph nodes

Progressive decrease of CD4+ T-cells

Architecture of folliculo-dendritic cells show disruption and decreased

trapping efficiency

III. ADVANCED STAGE ‘ADVANCED STAGE’

(0-200/mL CD4+ T-lymphocytes) *Complete disruption of folliculo-dendritic cells with dissociation

(-) Trapping function

Virus spills over to circulation

*At this point the cytotoxic / suppressor cells and natural killer cells are
outnumbered by the HIV virus (>200/mL CD4+ T-lymphocytes)

‘Opportunistic Infection’

‘DEATH’
Clinical Manifestations
A. 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.

 Typical clinical findings:

1. General
 Fever
 Pharyngitis
 Lymphadenopathy
 Headache
 Retro-orbital pain
 Arthralgias / myalgias
 Lethargy/malaise
 Weight loss/anorexia
 Nausea/vomiting/diarrhea
2. Neuropathic
 Meningitis
 Encephalitis
 Peripheral neuropathy
 Myelopathy
3. Dermatologic
 Erythematous maculopapular rash
 Mucocutaneous ulceration
B. 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
C. Early Symptomatic Disease (ARC or AIDS Related Complex)
 Clinical characteristics are the ff.
1. Generalized lymphadenopathy (>1cm)
 Extra-inguinal sites; >3 months; idiopathic
 Earliest symptoms ff. Acute syndrome
2. Oral lesions
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a. Thrush
o White, cheesy exudate – erythematous mucosa
o Soft palate are mostly affected
b. Oral hairy leukoplakia
o Filamentous white lesion (lateral borders of the tongue)
c. Aphthous ulcers of the posterior oropharynx
o Painful, interference swallowing
3. Reactivation “herpes zoster” or “shingles” (10-20%)
 1st clinical indication of immunodeficiency
 5 years following primary infection
4. Thrombocytopenia (3%; platelet 150,000)
 Bleeding gums, extremity petechiae, easy bruisability
D. AIDS (Full Blown)
 Opportunistic infection disease would set in like Pneumocystis Carinii, Pneumonia, TB, Kaposi’s Sarcoma & the
like
Complications
- The complications of HIV-related infections and neoplasms affect virtually every organ. The general approach to HIV-
infected person with symptoms is to 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. Abnormal findings range from completely non-specific to highly specific for HIV infection.
A. Gynecologic complications:
 Vaginal candidiasis
 Cervical dysplasia
 Neoplasia
 Pelvic inflammatory disease
B. HIV-related malignancies:
 Kaposi’s Sarcoma
 Non-Hodgkin’s carcinoma
C. Endocrinologic complication:
 Adrenal gland is the most commonly afflicted
D. Skin complications:
 Viral dermatitis
 Bacterial dermatitis
 Fungal dermatitis
 Neoplastic dermatitis
 Nonspecific dermatitis
E. Gastrointestinal complications:
 Candidal esophagitis
 Hepatic diseases
 Biliary diseases
 Enterocolitis
 Other disorders
 Gastropathy
 Malabsorption
F. CNS complications:
 Toxoplasmosis
 CNS lymphoma
 AIDS dementia complex
 Cryptococcal meningitis
G. Sinopulmonary complications:
 Pneumonia & other infectious pulmonary diseases
 Noninfectious pulmonary diseases
 Sinusitis
H. Oral lesions, retinitis, myopathy, and rheumatologic manifestations
I. Other systemic complaints
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.
A. Enzyme – Linked Immunosorbent Assay (ELISA)
 Standard screening test
 Extremely sensitive test
 Disadvantage: Low specificity
B. Western Blot Assay (WBA)
 Most common confirmatory test
- Tests for assessing disease progression:
 CD4+ T-cell count & Plasma HIV RNA assay are the most accurate assessment for disease
progression & time of death
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A. CD4+ T-cell Count

B. p24 Antigen Capture Assay
 Simplest test
C. Plasma HIV RNA Assay
 Most sensitive and reliable measurement of plasma viral load
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 can be modified by antiretroviral therapy and general medical support.
Medical / Surgical Management
A. Medical Management
 Management is usually supportive because there is no known cure for AIDS.
B. Pharmacological Management
 The corner stone of pharmacological management of HIV infection is ANTIRETROVIRAL therapy.
1. Nucleoside Analog Reverse Transcriptase Inhibitors (NARTI):
 Zidovudine (AZT)
 Zalcitabine (ddC)
 Lamivudine (3TC)
 Didanosine (ddl)
 Stavudine (d4T)
2. Protease Inhibitors:
 Saquinavir
 Ritonavir
 Indinavir
3. Non-nucleoside Reverse Transcriptase Inhibitor:
 Acvirapine
 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
o 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.
C. 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. 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 Evaluation
- Assess the general condition of the patient. Usual assessment of the patient includes:
1. Pulmonary test
2. UE and LE instability test
3. ROM
4. MMT
5. Motor and sensory tests
- Usual problems:
1. Impaired mobility
2. Difficulty with self-care
3. Impaired cognition
4. Uncontrolled pain
- Check for deconditioning problems:
1. Contracture
2. Adhesions
3. Atrophy
4. LOM
5. Weakness
6. Instabilities
7. Edema/swelling
- Specific tests suitable for conditions / complications present should be done and performed for confirmation.
PT Management
- Most important aspect of rehabilitation is to keep the patient as mobile as possible to prevent the complications
often associated with prolonged bed rest
A. To improve function:
 Gait and functional retraining
 Prevention of effects of deconditioning
 Use of adaptive equipment and strategies
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B. For impaired mobility, difficulty with self-care, 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
C. For cancer pain and pain in patients with HIV:
 Heat modalities
o 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
o Conventional high frequency setting is most effective