Last reviewed: 17 Sep 2021
Last updated: 11 Aug 2021

Summary

Definition

History and exam

Key diagnostic factors

  • no antiretroviral treatment (ART) or failure of ART
  • fever
  • headache and altered mental status
  • dyspnea or cough
  • abdominal pain, diarrhea, weight loss
  • dysphagia
  • lymphadenopathy
  • visual floaters and blindness
  • ocular hemorrhage
  • mucosal changes

Other diagnostic factors

  • hepatosplenomegaly
  • exercise-induced oxygen desaturation
  • cyanosis
  • blurred vision and photophobia
  • papilledema
  • meningismus, focal neurologic findings
  • pain and weakness
  • bone or joint pain
  • skin lesions

Risk factors

  • post-HIV seroconversion with any CD4+ cell count
  • CD4+ count below 200 cells/microliter
  • CD4+ count below 100 cells/microliter
  • CD4+ count below 50 cells/microliter
  • no antiretroviral treatment (ART) or failure of ART
  • men who have sex with men
  • black or Hispanic race, intravenous drug use
  • social factors (poverty, overcrowding, homelessness, poor nutrition)
  • lack of preventive treatment for latent tuberculosis (TB) and anergy
  • smoking

Diagnostic investigations

1st investigations to order

  • CD4+ cell count
  • sputum stain and culture
  • blood cultures
  • adenosine deaminase
  • cytomegalovirus cultures
  • cytomegalovirus (CMV) serology
  • peripheral blood leukocyte culture
  • cytomegalovirus (CMV) proteins in peripheral blood leukocytes (pp65) antigenemia
  • quantitative cytomegalovirus (CMV) polymerase chain reaction (PCR)
  • Toxoplasma gondii serology
  • cryptococcal polysaccharide antigen
  • CBC
  • liver function test
  • lactate dehydrogenase
  • ABG
  • chest x-ray
  • head CT

Investigations to consider

  • tuberculosis (TB) nucleic acid amplification
  • interferon gamma release assay (IGRA)
  • bronchoalveolar lavage (BAL)
  • oropharyngeal scrapings (KOH prep) and culture
  • cerebrospinal fluid (CSF) analysis
  • polymerase chain reaction (PCR): cerebrospinal fluid (CSF), bronchoalveolar lavage (BAL) fluid, and vitreous and aqueous humor specimen for Toxoplasma gondii
  • polymerase chain reaction (PCR): brain specimen for John Cunningham (JC) virus
  • bone marrow aspirate and culture
  • lymph node aspirate or biopsy
  • tissue biopsy
  • brain biopsy
  • abdomen CT
  • high-resolution CT (HRCT) of the chest
  • brain MRI
  • gallium-67 (Ga-67) lung scan
  • indium 111-diethylenetriaminepentaacetic acid (DTPA)-IgG scan
  • thallium single photon emission tomography and PET
  • upper gastrointestinal endoscopy and colonoscopy

Treatment algorithm

Contributors

Authors

Ruth Byrne, MBBS, MRCP

Consultant Physician

Chelsea and Westminster Hospital

London

UK

Disclosures

RB declares that she has no competing interests.

Mark Nelson, MA, MBBS, FRCP

Consultant Physician

Chelsea and Westminster Hospital

London

UK

Disclosures

Not disclosed.

Acknowledgements

Dr Ruth Byrne and Dr Mark Nelson would like to gratefully acknowledge Dr Irene Alexandraki, a previous contributor to this topic.

Disclosures

IA declares that she has no competing interests.

Peer reviewers

Colm O'Mahony, MD, FRCP, BSc, DIPVen

Consultant in Sexual Health

Department of Sexual Health

Countess of Chester Hospital NHS Foundation Trust

Chester

UK

Disclosures

CO declares that he has no competing interests.

Nicola Steedman, MRCP, DipGUM, DipHIV

Consultant Physician in Sexual Health and HIV

Department of Sexual Health

Countess of Chester Hospital NHS Foundation Trust

Chester

UK

Disclosures

NS declares that she has no competing interests.

William R. Rodriguez, MD

Assistant Professor of Medicine

Massachusetts General Hospital

Charlestown

MA

Disclosures

WRR declares that he has no competing interests.

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