The principal causes of liver failure in an AIDS patient are: infections (tuberculosis, atypical mycobacteria, CMV, hepatitis B and C), septicaemia, cryptosporidia cholangitis, extrapulmonary pneumocystosis), drugs (anti-TB medication, paracetamol overdose, antiviral medication), alcohol. Pancreatitis can be induced by medication, such as Hivid® and Videx®.
Fever can, among other things, be due to tuberculosis or opportunistic infections. Investigations in an AIDS patient with fever should be aimed at detecting treatable causes. Malaria is not an opportunistic infection, but can also occur in HIV patients. Recurrent Salmonella septicaemia is frequent. The reason is that Salmonella bacteria are facultative intracellular pathogens. They are normally eradicated by T-cell-activated macrophages. This mechanism is deficient in AIDS patients. A “functional hypogammaglobulinaemia” exists despite the polyclonal B-cell stimulation and the accompanying hypergammaglobulinaemia. There is an increased risk of infections with encapsulated bacteria (e.g. pneumococci), but also with Branhamella, Haemophilus and Staphylococcus. Infections with Mycoplasma and Legionella are not more frequent in seropositive persons. “Drug fever” occurs more frequently in seropositive than in seronegative persons.
In Africa persistent cough lasting more than 1 month occurs in approximately one third of AIDS patients. Bacterial pneumonia (pneumococci, Haemophilus) and tuberculosis are prominent in cases of respiratory problems. Atypical mycobacterioses and Pneumocystis carinii pneumonia are rather infrequent in Africa. Deep fungal infections (histoplasmosis, cryptococcosis, blastomycosis) can likewise cause pulmonary lesions. Pneumocystosis usually develops subacutely, with dyspnoea (shortness of breath) and a dry cough. Recurrent bacterial pneumonia occurs frequently in AIDS patients and is a major cause of death. Vomiting blood (haemoptysis) and pleural effusions are principally caused by TB and Kaposi's sarcoma. Sinusitis is quite frequent in AIDS patients. Lymphoid interstitial pneumonitis occurs especially in children, but can also be found in HIV positive adults. It is characterised by diffuse interstitial infiltrates. The alveolar septa are infiltrated with lymphocytes, plasma cells and immunoblasts.
Various abnormalities are of course possible, but these can be roughly divided schematically into:
Ring-enhanced single lesion: abscess, with frequency toxoplasmosis > TB > cryptococcosis. The peripheral staining by the contrast medium shows the oedema zone around the abscess. On this basis a test therapy will often be started without having formal proof of toxoplasmosis. If there is no improvement within two weeks or if deterioration occurs, a stereotactic brain biopsy should be performed. In addition to these three etiologies, there can be other causes of an intracranial mass: herpes, Histoplasma, Nocardia, Candida, Kaposi, metastasis. In 10% of cases no specific cause is found.
Non-ring enhanced lesion: probably lymphoma > PML. In case of PML there is no mass effect.
Bilateral diffuse lesions: immune reconstitution syndrome if in the correct context.
Multiple ring lesions: toxoplasmosis >> tuberculosis.
HIV atrophy: broadened sulci and enlarged ventricles (DD internal hydrocephalus: flattened sulci and enlarged ventricles).
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