Internal Medicine

0521779407-C03 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:54

Complications of Human Immunodeficiency Virus Type 1 387

immune reconstitution after therapy for HIV, secondary may be

stopped in the following settings:

■CMV: consider in patients with CD4 >100/mm^3 after≥6 months

of HAART with quiescent retinitis; if anti-CMV therapy stopped.

Should have dilated funduscopic exams on a regular basis and ther-

apy restarted if recrudescence of retinitis or CD4 <50/mm^3.

■Cryptococcal meningitis: recent data suggest that may be able to stop

maintenance therapy if asymptomatic for >1-2 years and no evidence

of cryptococcal infection during that period (though role of ongoing

cryptococcemia unclear)

■MAC: may be considered if no MAC symptoms

■Toxoplasmosis: no data at this time

complications and prognosis

Complications

See under individual pathogens for details.

Be aware of OI “Reversal Syndromes” after beginning HAART:

■MAC: Lymphadenitis, high fever, lung infiltrates; onset 1–12 weeks

■CMV: Retinitis and vitritis; onset 1-2 months. Uveitis and macular

edema, epiretinal membrane formation, cataracts, papillitis; Onset

2 months–2 yrs.

■TB: Fever, worsening lung infiltrates/effusion, mediastinal and

peripheral lymphadenopathy; Onset 1–6 weeks

■Crptococcal meningitis: new meningeal signs and symptoms,

increased WBC in CSF, adenopathy; Onset 1 week-8 months.

“Reversal” syndromes can be prevented and managed by obtaining

mycobacterial blood culture and ophthalmologic exam and initiating

MAC prophylaxis (for at least 1 month, if possible) before initiating

HAART inn patients with CD4 <50/mm^3 ; giving brief course of corti-

costeroids in severe cases of mycobacerial “reversal” syndrome. Most

cases resolve in several weeks by continuing HAART and anti-OI medi-

cations. Invasive diagnostic procedures can be avoided if clinical setting

and presentation is typical.

Prognosis

■Most important means of improving prognosis from opportunistic

infections is improvement of host immune function – i.e. immune

reconstitution with HAART. HAART improves T-cell counts but

unclear if improves T-cell diversity, which may be the key to complete

immune restoration; if HAART does not fully restore T-cell diversity,

then HIV+persons may be at some long-term risk for opportunistic

infections and malignancies.