The complications of HIV-related infections and neoplasms affect virtually every organ. The general approach to the HIV-infected person with symptoms is to evaluate the organ systems involved, aiming to diagnose treatable conditions rapidly. As can be seen in Figure 31–1, the CD4 lymphocyte count result enables the clinician to focus on the diagnoses most likely to be seen at each stage of immunodeficiency. Certain infections may occur at any CD4 count, while others rarely occur unless the CD4 lymphocyte count has dropped below a certain level. For example, a patient with a CD4 count of 600 cells/mcL, cough, and fever may have a bacterial pneumonia but would be very unlikely to have Pneumocystis pneumonia.
Relationship of CD4 count to development of opportunistic infections. MAC, Mycobacterium avium complex; CMV, cytomegalovirus; CNS, central nervous system.
Many individuals with HIV infection remain asymptomatic for years even without antiretroviral treatment, with a mean time of approximately 10 years between infection and development of AIDS. When symptoms occur, they may be remarkably protean and nonspecific. Since virtually all the findings may be seen with other diseases, a combination of complaints is more suggestive of HIV infection than any one symptom.
Physical examination may be entirely normal. Abnormal findings range from completely nonspecific to highly specific for HIV infection. Those that are specific for HIV infection include hairy leukoplakia of the tongue, disseminated Kaposi sarcoma, and cutaneous bacillary angiomatosis. Generalized lymphadenopathy is common early in infection.
The specific presentations and management of the various complications of HIV infection are discussed under the Complications section below.
et al. Neurologic sequelae of primary HIV infection. Handb Clin Neurol. 2018;152:65.
B. Molecular mechanism of HIV-1 entry. Trends Microbiol. 2019;27:878.
et al. Dolutegravir plus lamivudine dual therapy—a new option for initial antiretroviral therapy. Drugs Today (Barc). 2019;55:297.
et al. Peripheral ulcerative keratitis with corneal melt as the primary presentation in a case of human immunodeficiency virus. BMJ Case Rep. 2019;12:e226936.
Specific tests for HIV include antibody, antigen, and viral load detection (Table 31–2). Initial testing for HIV should be done using a fourth-generation HIV antigen/antibody immunoassay. It detects HIV-1 and HIV-2 antibodies and HIV-1 p24 antigen. Reactive specimens are then tested with an HIV-1/HIV-2 differentiation immunoassay to confirm infection and to distinguish HIV-1 from HIV-2. For patients who are reactive on both tests, the sensitivity and specificity for chronic HIV approaches 100%. Patients who have a reactive HIV antigen/antibody immunoassay but a negative HIV-1/HIV-2 differentiation immunoassay should have a HIV-1 viral load test (nucleic acid ...