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Gatot Sugiharto, MD, Internist Internal Medicine Department Faculty of Medicine, Wijaya Kusuma University Surabaya
Gatot Sugiharto, MD, Internist Internal Medicine Department Faculty of Medicine, Wijaya Kusuma University Surabaya
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HIV Prevention
• Currently, there is no vaccine to prevent HIV
infection nor is there a cure for HIV/AIDS. To
reduce risk of becoming infected with HIV or
transmitting the virus to others:
• Get tested regularly for HIV
• Practice abstinence
• Remain faithful to your spouse or partner
• Consistently use male latex or female
polyurethane condoms
• Do not share needles
Treatment
• Antiretroviral drugs (ARVs)
– Are not a cure
– Slow down the process of replication of HIV in
the human body
• Prevent and treat Opportunistic Infections
• Prevent mother-to-child-transmission
– During pregnancy and delivery
– Safer infant feeding
• Access to services / availability of drugs
• Availability, Coverage, Impact
Antiretroviral Drugs
• Class:
– Nucleoside Reverse Transcriptase inhibitors (NRTI)
– Non-Nucleoside Transcriptase inhibitors (NNRTI)
– Protease inhibitors (PI)
• Do not cure people of HIV or AIDS rather,
they suppress the virus, even to undetectable
levels, but they do not completely eliminate HIV
from the body lead longer and healthier
lives can still transmit the virus
Sinonym
• THE COCKTAIL’
• COMBINATION THERAPY
• ARVS (ANTI-RETROVIRALS)
• ANTI-HIV THERAPY
• Tenofavir Viread
• Indinavir Crixivan
• Nelfinavir PI Viracept
• Lopinavir / ritonovir Kaletra
Opportunistic infection?
• Also called OI
• An infection or illness that takes the
OPPORTUNITY to cause an illness in a person
who is immunocompromised
• Opportunistic infections are more common
in persons who have a lower CD4 count
• HIV doesn’t kill OI’s kill
• Most OIs are treatable/curable
• Some are preventable
• Early treatment for OIs prolongs life!
CD4 count and OIs
TB
PCP, thrush
Toxo, Esoph
thrush
Below 200
PML
Opportunistic Infections associated
with AIDS
• Bacterial, parasitic, and other infections
• Serious and recurrent bacterial infections, syphilis,
toxoplasmosis, crypto/microsporidiosis
• Mycobacterial infections
• MTB, MAC
• Fungal infections
• Pneumocystis jiroveci pneumonia, Candida,
cryptococcosis, histoplasmosis, coccidioidomycosis
• Viral infections
• CMV, HSV, HZV, HPV, HCV, HBV
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Management of TB in HIV pos
persons
• If pts started ARV and TB therapy together
there was an increased risk of progression to
Aids
• CD4 <200 where main problems were seen
and it was much better to delay antiretroviral
therapy start Tx TB first
• CD4 > 200 there was no difference when it
was started
Gatot Sugiharto, MD, Internist
Internal Medicine Department
Faculty of Medicine, Wijaya Kusuma
University Surabaya
Filariae Lymphatic filariasis and elephantiasis 120 million Not fatal but 40
million
disfigured or
incapacitated
Trypanasoma cruzi Chagas disease (cardiovascular) 13 million 14,000
common
Symptoms - signs – 3 stages
1. Asymptomatic stage
• There is internal damage to the lymphatics
and kidneys
2. Acute stage – Filarial lymphangitis
• Characterised by bouts of fever
• heat, redness, pain, swelling and
tenderness of the lymph nodes and ducts
3. Chronic stage
• Usually results in elephantiasis as a result
of chronic lymphoedema
• There is a massive overgrowth of tissue
resulting in severe deformities
Elderly male with massive • The legs are often affected and result in
hydrocoele, and elephantiasis of inability to walk
the leg. Also has nodules in the
groin due to onchocerciasis • The scrotum is often affected in men and
(source: WHO/TDR/Crump)
the breasts and vulva in women
Diagnosis
• Microscopic examination of Giemsa stained thick blood films
for the presence of microfilariae
• W. bancrofti shows marked nocturnal periodicity, so it’s best
to collect blood samples between 10pm and 1 am
• Serology test
Treatment
• Diethylcarbamazine (DEC) rapidly kills microfilariae and will
kill adult worms if given in full dosage over 3 weeks
• Release of antigens from dying microfilaria causes allergic-
type reactions – add an antihistamine and aspirin to
treatment regimen
• Other treatment options are
– ivermectin
destruction
Life cycle
• Cysts are passed in feces(1). Infection by Entamoeba histolytica occurs by
ingestion of mature cysts in fecally contaminated food, water, or hands (2).
• Excystation occurs in the small intestine(3) trophozoites released
migrate to the large intestine (4). Trophozoites multiply by binary fission and
produce cysts (5) passed in the feces.
• Cysts (protected by their cell walls) can survive days to weeks in the external
environment and are responsible for transmission.
• In many cases, trophozoites remain confined to the intestinal lumen
(noninvasive infection) of individuals who are asymptomatic carriers, passing
cysts in their stool.
• In some patients trophozoites invade the intestinal mucosa (intestinal disease),
or, through the bloodstream, extraintestinal sites such as the liver, brain, and
lungs (extraintestinal disease), with resultant pathologic manifestations.
• Invasive and noninvasive forms represent two separate species (E. histolytica &
E. dispar respectively), however not all persons infected with E. histolytica will
have invasive disease. These two species are morphologically indistinguishable.
• Transmission can also occur through fecal exposure during sexual contact
(cysts, & also trophozoites could prove infective).
Trophozoites of Entamoeba histolytica (Trichrome stain).
Two diagnostic characteristics: Two of the trophozoites have ingested
erythrocytes, and the nuclei have typically a small, centrally located
karyosome
Clinical Manifestations
Amebic colitis
Sign or Symptom % of Patients Affected
Symptoms > 1 wk Most patients
Diarrhea 94-100
Dysentery 94-100
Abdominal pain 12-80
Weight loss 44
Fever >38oC 10
Heme (+) stool 100
Immigrant from or traveler
to endemic area >50
Prevalence (male/female) 50/50
Clinical Manifestations
Asymptometic amebiais:
• Luminal agent (paromomycin, diloxanide
furate, or iodohydroxyquin)
• Amebic Colitis: Metronidazole & a
luminal agent
• Amebic Liver Absces : Metronidazole &
a luminal agent
Prevention
Although the adult form of these intestinal nematodes can be distinguished, the
diagnostic form in humans, the ova, are essentially identicall, oval and measure about
60 X 40 µm, typically a clear space between the embryo and the thin shell.
(unstained wet-prep)
Treatment
• Mebendazole (100 mg twice daily X 3 days) or
• Albendazole (400 mg as a single dose)
– Mebendazole is poorly absorbed and may not eradicate
developmentally arrested Ancylostoma larvae residing in
extraintestinal issues. Therefore periodic follow up stool
examination may be necesessary
• Alternate Treatment:
– Pyrantel pamoate (11 mg/kg up to 1 gm/day, X 3 days)
• Re-infection in endemic areas occur so commonly that
the effect of single course of treatment is of
questionable benefit
• Iron supplementaion reverses mild to modertae
hookworm anemis
Tapeworms : Taenia saginata and Taenia solium
• T. saginata:
– Widespread in cattle breeding areas of the world
– Prevalence >10% in some independent states of the former
Soviet Union, in Near East, and in central and eastern Africa.
– Lower rates : in Europe, Southeast Asia, & South America
• T. solium:
– Prevalent in Mexico, Central and South America, Africa,
Southeast, Asia,and the Philippines
– Infections in USA and Canada are found in immigrants from
areas where taeniasis is endemic, and in travelers who consume
undercooked meats in endemic areas
Pathology