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, eye pain, and blindness
- ocular hemorrhage
- mucosal changes
Other diagnostic factors
- hepatosplenomegaly
- exercise-induced oxygen desaturation
- 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 count
- CD4 count below 250 cells/microliter
- 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 (MSM)
- black or Hispanic race
- intravenous drug use
- social factors (poverty, overcrowding, homelessness, poor nutrition)
- dust inhalation in areas endemic for Coccidioides
Diagnostic tests
1st tests to order
- CD4 cell count
- sputum stain and culture
- blood cultures
- adenosine deaminase
- cytomegalovirus (CMV) serology
- quantitative cytomegalovirus (CMV) polymerase chain reaction (PCR)
- Toxoplasma gondii serology
- Coccidioides serology
- cryptococcal polysaccharide antigen
- CBC
- liver function test
- lactate dehydrogenase
- ABG
- chest x-ray
- head CT
Tests to consider
- tuberculosis (TB) nucleic acid amplification
- lateral flow urine lipoarabinomannan (LF-LAM) assay
- 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
- bone marrow aspirate and culture
- lymph node aspirate or biopsy
- tissue biopsy
- brain biopsy
- abdominal CT
- high-resolution CT (HRCT) of the chest
- brain MRI
- thallium single photon emission tomography and PET
- upper gastrointestinal endoscopy and colonoscopy
- coccidioidal antigen testing
- polymerase chain reaction (PCR) for Coccidioides
Treatment algorithm
Mycobacterium tuberculosis infection
disseminated M avium complex
Pneumocystis jirovecii pneumonia
Toxoplasma gondii infection encephalitis
cryptococcal meningitis
cytomegalovirus
mucocutaneous candidiasis
coccidioidomycosis
Contributors
Authors
Jake Scott, MD
Clinical Assistant Professor
Infectious Diseases and Geographic Medicine
Stanford University School of Medicine
Antimicrobial Stewardship Program Medical Director
Stanford Health Care Tri-Valley
Pleasanton
CA
Disclosures
JS declares that he has no competing interests.
Acknowledgements
Dr Jake Scott would like to gratefully acknowledge Dr, Ruth Byrne, Dr Mark Nelson, and Dr Irene Alexandraki, previous contributors to this topic.
Disclosures
RB, MN, and IA declare that they have 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.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: Mycobacterium tuberculosis. 2024 [internet publication].Full text
World Health Organization. Guidelines for diagnosing, preventing and managing cryptococcal disease among adults, adolescents and children living with HIV. Jun 2022 [internet publication].Full text
Griffith DE, Aksamit T, Brown-Elliott BA, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med. 2007 Feb 15;175(4):367-416.Full text Abstract
Perfect JR, Dismukes WE, Dromer F, et al. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis. 2010 Feb 1;50(3):291-322.Full text Abstract
Pappas PG, Kauffman CA, Andes DR, et al. Clinical practice guideline for the management of candidiasis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis. 2016 Feb 15;62(4):e1-50.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Pneumonia
- Diarrhea
- Meningitis
More DifferentialsGuidelines
- Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV
- European AIDS Clinical Society: guidelines version 12.0
More GuidelinesPatient information
Tuberculosis
Toxoplasmosis in pregnancy: what is it?
More Patient information
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