化疗方案（列举2个初治常见化疗方案如下，更多治疗方案见国家结核病防治指南）：

　　①2HRZE / 4HR：强化期：二个月、H、R、Z、E、每日一次；继续期：四个月，H、R每日一次。②2H3 R3 Z3 E3 / 4H3 R3：强化期：二个月、H、R、Z、E、隔日一次；继续期：四个月、H、R、隔日一次。

　　3．预防

　　指征：艾滋病病人不是必须对结核病进行化学药物预防，但临床医生可参考以下意见进行预防性化疗：病人的CD4+ T淋巴细胞计数〈200/mm3 时，可进行预防性化疗，其方案是：①异烟肼+利福喷丁，连续服用4-6个月（剂量见上表）。②异烟肼，连续服用12个月（剂量见上表）。

　　（三）分支杆菌感染

　　1．诊断

　　分支杆菌感染的临床症状同活动性结核病相似，但全身播散性病变更为常见。确诊：血培养、痰培养、支气管肺组织活检、痰支气管冲洗物培养为非结核分枝杆菌。

　　2．治疗

　　其它分支杆菌治疗同结核病的治疗。

　　鸟分支杆菌（MAC）治疗：首选治疗方案:克拉霉素500 mg /次，2次/日或(阿奇毒素600mg /日) +乙胺丁醇15 mg/kg /日（分次服），重症病人可同时联合应用利福布汀（300-600 mg /日）或阿米卡星（10 mg/kg/次肌肉注射，1次/日），疗程6个月。替代治疗方案：利福布汀（300-600 mg /日）+阿米卡星（10 mg/kg/次肌肉注射，1次/日）+环丙沙星（750 mg/次，2次/日），疗程6个月。

　　3．预防

　　艾滋病病人不是必须对非结核分枝杆菌病进行化学药物预防，医生根据临床可参考以下意见。艾滋病病人，当CD4+ T淋巴细胞<50/mm3者，可预防性治疗，以减少发生播散性MAC的机率。方案是克拉霉素500mg/次，2次/日；或阿齐霉素，1200mg/周。如病人经HAART治疗使CD4+ T淋巴细胞增加到>100/mm3并持续≥6个月时，可停止预防用药。

　　（四）巨细胞病毒视网膜脉络膜炎

　　1．诊断

　　临床常见的表现为快速视力下降，确诊有赖于眼底镜检查。

　　2．治疗

　　（1）更昔洛韦　5mg/kg/日，分为2次静滴，2-3周后改为5mg/kg/日，每日1次，静滴，终身维持。可引起白细胞减少，血小板减少和肾功能不全。病情危重或单一药物治疗无效时可联用膦甲酸钠 90mg/kg 静滴，每日2次。若为视网膜炎亦可球后注射更昔洛韦。

　　（2）膦甲酸钠 90mg/kg 静滴，每日2次 ，应用2-3周后改为长期90mg/kg 静滴，每日1次，可导致肾功能不全，恶心及电解质紊乱，若肌酐清除率异常，则需调整剂量。

　　3．预防

　　对于CD4+T淋巴细胞计数<200/mm3的AIDS的病人，应定期检查眼底。一旦出现CMV病，应积极治疗，在疾病控制之后需终身服药以预防复发。对于CD4+ T淋巴细胞计数<50/mm3的AIDS的病人应常规给予预防服药（更昔洛韦口服），在经HAART治疗有效的病人若其CD4+ T淋巴细胞计数>100/mm3且持续6月以上时可以考虑停止预防给药。

　　（五）弓形虫脑病

　　1．诊断

　　弓形虫脑病常发生在CD4+ T淋巴细胞计数<100/ mm3的患者。表现为局灶性或弥漫性中枢神经系统损害，有头痛、低热、嗜睡、躁动和昏睡，局灶症状包括癫痫和中风，。其它症状包括：复视、偏盲、失明、步态不稳、肌阵挛、颤动、人格改变、幻觉和晕厥。脑膜炎不常见。头颅CT为一个或多个低密度病灶，增强扫描呈环状或结节样增强。头颅MRI较CT更敏感，典型的MRI表现为颅内多发长T1和长T2信号。确诊依靠脑活检。

　　2．治疗

　　首选治疗：乙胺嘧啶（负荷量100mg，口服，2次/日，此后50-75mg/日维持）+磺胺嘧啶（1-1.5g，口服，4次/日），疗程一般为3周，重症患者和临床、影像学改善不满意患者疗程可延长至6周以上。不能耐受者和磺胺过敏者可以选用克林霉素600mg/次，静脉给药，每6小时给药一次，联合乙胺嘧啶。为减少血液系统不良反应，合用甲酰四氢叶酸10－20mg/日。

　　3．预防

　　对无弓形虫脑病病史但CD4＋ T细胞计数<100/mm3且弓型体抗体IgG阳性的病人应常规用复方新诺明2片/日预防，对既往患过弓形虫脑病的病人要长期用乙胺嘧啶（25-50mg/日）+联合磺胺嘧啶（2-4g/日）预防。病人经HAART治疗使CD4+ T细胞增加到>200/mm3并持续≥3-6个月时，可停止预防用药。对弓形虫抗体阴性且CD4＋ T细胞计数<100/mm3的病人应避免弓形虫感染。具体措施包括：肉类食物应在－20℃冷藏；肉类食物要煮熟(至少60℃以上)以杀灭组织中的包囊；蔬菜水果要清洗干净；不养宠物。

　　（六）真菌感染

　　1．诊断

　　临床诊断为真菌感染，常见的是念珠菌感染和新型隐球菌感染。

　　2．治疗

　　（1）念珠菌感染

　　口腔念珠菌感染的首选治疗是制霉菌素局部涂抹加碳酸氢钠漱口水漱口，如果对上述治疗无反应，可以给予如下治疗：氟康唑：50mg-100mg/次，口服，1次/日，疗程1-2周。食道念珠菌感染：氟康唑首剂200mg/日，后改为100mg /次，1次/日, 应用1-2周；重症病人氟康唑可增加剂量和延长疗程。对复发性念珠菌感染建议氟康唑100mg/日，长期服用。

　　（2）新型隐球菌脑膜炎

　　1）降颅压治疗：首选甘露醇，重症者可行侧脑室外引流。

　　2）抗真菌治疗：首选两性霉素B，先从每天1mg，加入5%的葡萄糖水中500ml缓慢静点（不宜用生理盐水，需避光），滴注时间不少于6-8小时。第二天和第三天各为2 mg和5 mg，加入500ml的葡萄糖水中滴注。若无反应第四天可以增量至10mg。若无严重反应，则以后按5mg/日增加，一般达30-40 mg（最高剂量50mg/日）。疗程需要3个月以上，两性霉素B的总剂量为2-4g。两性霉素B不良反应较大，需严密观察。二性霉素B与5-氟胞嘧啶（5FC）合用具有协同作用。5FC为100mg/kg/日（1.5g-2.0g，3/日），二者共同使用至少8-12周。二性霉素B也可与氟康唑联合使用，用法为氟康唑200mg/日，口服或静滴，疗程8-12周。

　　3）必要时可由脑室引流管注射两性霉素B 0.5-1mg/次，隔日一次。

　　4）病情稳定后可改用氟康唑维持，200mg/次，1次/日，长期维持，以预防复发。

AIDS immune pathology, the pathological changes of AIDS, anti-HIV immune response and the course of HIV infection, AIDS Clinical manifestations and staging, the diagnostic criteria, common diagnosis and treatment of opportunistic infections and prevention

AIDS is a multi-organ system involvement of systemic diseases. HIV infection of immune system disease, multiple system opportunistic infections (including parasites, viruses, bacteria and fungi) and malignant (including Kaposi's sarcoma, malignant lymphoma and cervical cancer) AIDS poses a complex clinical pathological changes.

(A) the common opportunistic infections and malignancies

1. Lung disease spores

The main disease caused by pneumocystis carinii pneumonia lung.两肺showed diffuse involvement, it is changed, the weight increase in a significant reduction in gas. By the formalin-fixed, the pulmonary cavernous rough cut surface. Alveolar cavity with characteristic appears, the bubble-shaped, red dye, no effusion cell, known as the honeycomb-like exudate. Alveolar epithelial cell hyperplasia cubic-shaped. Pneumocystis carinii cysts in the alveolar cavity effusions, showed aggregated distribution. Indian film, the use of Gram or Giemsa staining, the trophozoites can be displayed clearly. The use of Giemsa staining clearly shows that Pneumocystis carinii cyst.

2. Toxoplasmosis

Although disseminated toxoplasmosis may also be involved eyes, lungs, heart and gastrointestinal tract, but the majority of patients with Toxoplasma encephalitis. Brain lesions can be limited or diffuse. Basal ganglia in the brain cortex and cerebellar abscess occurred, and into the subarachnoid space. Toxoplasma brain abscess in the CT examination to enhance contrast with the characteristic changes in one or more lesions were made, is located in gray matter, showing the cystic structure enveloping the ring. Regional cerebral hemorrhage coagulative tissue necrosis, necrosis of a small number of Toxoplasma region. There is a necrotic area around the congestion zone and vascular endothelial hyperplasia, hyperplasia with severe inflammation with infiltration and contains scattered多量of Toxoplasma tachyzoites and the ease with sub-yield false cyst. Within the brain tissue of tachyzoites with other organizations of the different, were round or oval-shaped, rather than positive crescent. In other tissues, H & E staining can be clearly observed that the half-moon 2 ~ 3μm and 50μm tachyzoites cyst cyst or false. In addition, serum antibody titers to Toxoplasma gondii infection increased with the significance of prompt diagnosis.

3. White candidiasis

AIDS patients, patients with recurrent Candida albicans is the most common opportunistic fungal infection. Candida albicans in patients with oral tongue surface coverage as a result of exudation, was filled with white patches, or even form a thick cover of dark brown. Candida albicans mouth disease indicative of AIDS disease has entered a period. Any part of the gastrointestinal tract can be affected.道白gastrointestinal esophageal candidiasis is the most commonly involved site. Gray pseudome mucosal surface can be seen, as well as irregular-shaped ulcers. Pseudome from cellulose and tissue necrosis, which can be seen in the pseudohyphal mesh. Candida albicans disseminated disease often involving multiple organs, such as the kidney (about 80%), brain (about 50%) and heart (about 58%), in the involvement of multiple organs with abscess formation. Histological examination showed Candida albicans from yeast-like spores or blastospore (diameter of about 3 to 4μm, were round or oval) and pseudohyphal (by the string-like spores pose).

4. Mycobacterial disease

AIDS patients often Mycobacterium, including Mycobacterium tuberculosis and infected birds.

AIDS, tuberculosis occurred in the early and late course of disease. Common extra-pulmonary TB, more invasive, the body prone to proliferation. Microscope, AIDS patients are not typical of tuberculosis granuloma, caseous necrosis significantly, epithelioid cells and giant cell less. TB often exudative lesions, gas chamber is changed, there are cellulose, neutrophils and tissue cells. Extensive necrosis can be seen frequently and the acid-fast Mycobacterium tuberculosis多量.

Mycobacterium infection in birds can be found in advanced HIV disease, when the number of CD4 + T lymphocytes is usually less than 100/mm3, often caused by disseminated mycobacterial disease. In the spleen, liver, lymph nodes, heart and kidney can be seen sometimes cut miliary granuloma. Microscope, the local structure of cell mass organizations have been replaced by a high degree of tissue swelling, striped or bubble-like, cytoplasmic staining yellow or blue staining, nuclear staining of deep, minimal formation of giant cells, with little or no necrosis, no calcification and fibrosis. Acid-fast staining showed that macrophages swelling, a large number of birds with Mycobacterium.

5. Cytomegalovirus infection

AIDS patients with cytomegalovirus infection can cause gastrointestinal ulcers, interstitial pneumonitis, glomerular nephritis, retinitis. CMV can also be infected with brain and spinal cord of all parts, including spinal nerve roots and cranial nerves. Autopsy examination, adrenal gland and the most commonly involved the respiratory system. Microscope, we can see some large cell, the nucleus and cytoplasm, there are obvious, the inclusion body clearance sector. In all human viruses, cytomegalovirus inclusion bodies is the largest of the infected cells within the nucleus and the cytoplasm may occur. Cytomegalovirus inclusion bodies expressed as: ① double staining of nuclear inclusion body surrounded by a transparent halo enveloping, like owl-like eyes; ② double staining of the cytoplasm or eosinophilic inclusion bodies; ③ epithelial cells, endothelial cells, giant macrophage and smooth muscle cells can be seen in inclusion body. Immunohistochemistry, DNA in situ hybridization and PCR confirmed contribute.

6. Kaposi's sarcoma

Kaposi's sarcoma in AIDS patients is the most common tumor. Epidemic Kaposi's sarcoma or AIDS-related Kaposi's sarcoma and other types of different: ① homosexual or bisexual men mostly, but also shows that intravenous drug users; ② lesions for the multi-center, more invasive, involving not only the skin and visceral involvement (about 75% of cases involving internal organs), followed by lung, lymph nodes, gastrointestinal tract, liver, urogenital system, and even a small number of affected adrenal gland, heart and spleen. Kaposi's sarcoma skin red or purple-red, flat spots early to; then, the development of the plaque for the uplift; ultimately the formation of nodules, and erosion occurred, ulcers. Posed by the spindle cell tumors, blood vessels can form cracks, which can be seen inside the red blood cells, tumor cells with endothelial cells and smooth muscle cell characteristics. Human herpesvirus 8 with Kaposi's sarcoma related to the occurrence of.

(B) pathological changes in the immune system

Lymphadenopathy associated 1.HIV

HIV-related lymphadenopathy can generally be broken into non-follicular follicular hyperplasia, follicular broken follicular hyperplasia, follicular follicular degradation and depletion of four types. Prior to the occurrence of AIDS, patients with persistent generalized lymphadenopathy, enlarged lymph nodes are generally not more than 3cm, the majority of HIV-infected persons prior to the occurrence of lymph node in AIDS histological changes for follicular hyperplasia; AIDS patients small lymph nodes, follicular lymph node disease degradation or depletion.

2. Splenic pathologic changes

Splenomegaly is common in patients with clinical AIDS symptoms. Adult patients weighing more than 400g of spleen, the spleen often means that there are opportunistic infections and malignant tumors occur. AIDS significant splenic lesions is a high degree of depletion of lymphocytes, only a small amount of white pulp, white pulp or even completely disappear.

AIDS children for significant changes in spleen lymphocyte depletion and the red blood cell phagocytosis phenomenon, about 50% of cases of Kaposi's lesions appear.

3. Thymic pathological changes

Adult AIDS patients with no significant pathological changes in thymus, B cells can occur follicular hyperplasia.

Thymus of children with AIDS premature degradation occurred. HIV thymic epithelial injury, caused by lymphoid tissue atrophy and depletion, showing plasma cell infiltration and formation of multinucleated giant cells. The formation of thymic cyst body.

4. The pathological changes in bone marrow

Early, 3 / 4 cases showed cells to granulocyte and megakaryocyte cell line-based cell proliferation. Late failure in patients with bone marrow cells decreased, showing immature and dysplastic myeloid precursors, lymphoid cells, atypical megakaryocytes, fine mesh sclerosis, mild vascular proliferation, tissue hyperplasia and hemosiderosis Huang Su-deposition.

AIDS immunopathological


Immunopathological

1.CD4 + T lymphocytes reduce the number of

After HIV infection in vivo number of CD4 + T lymphocytes in the steady decline in acute infection period in the number of CD4 + T lymphocytes in a short period of transient is characterized by a rapid decline in the majority of infected persons without special treatment, CD4 + T lymphocytes can be restored to normal on its own the level of or close to normal levels; asymptomatic infection to the number of CD4 + T lymphocytes characterized by the continued slow decrease, CD4 + T lymphocytes in a number of more than 800 ~ 350/mm3 in between the duration of this period of change in the larger (a few months to more than a dozen years), average duration of about 8 years; symptoms after entering the CD4 + T lymphocytes to a faster reduction in the majority of infected CD4 + T lymphocyte number below 350/mm3, some terminally ill people the number of CD4 + T lymphocytes even fell below 200/mm3, and rapid reduction.

CD4 + T lymphocytes is to reduce the number of factors, may be due to CD4 + T lymphocytes increased the damage; CD4 + T lymphocytes have reduced; detained peripheral lymphoid tissue of CD4 + T lymphocytes and so on.

2.CD4 + T lymphocyte dysfunction

Is mainly expressed in T helper cell 1 (Th1) cells are T helper cell 2 (Th2) cells instead of, antigen-presenting cell function is impaired, Interleukin-reduction and -2 have a response to antigen activation of incapacity, so that HIV / AIDS patients prone to various infections.

3. Abnormal immune activation

Another HIV infected immune changes in the abnormal activation of the immune system, CD4 +, CD8 + T lymphocyte expression of CD69, CD38 and HLA-DR immune activation markers such as abnormal levels rise, and with HIV plasma viral load have a good relevance, and with disease progression, cell activation levels are rising. Therefore, the abnormal state of immune activation can be measured not only in plasma viral load changes, but also can predict the CD4 + T lymphocytes reduce the speed.

4. Immune reconstitution

HAART has proven to immune function in AIDS patients the reconstruction field of AIDS research in recent years, significant progress in the one of the Treatment and Research AIDS impact. Immune function in AIDS patients is the meaning of the reconstruction by the anti-viral treatment, the above-mentioned HIV caused by abnormal immune changes can return to normal or near normal levels, namely: 1) reduction of the CD4 + T lymphocytes returned to normal; 2) CD4 + T lymphocyte antigen to stimulate the resumption of the memory capacity of a normal reaction; 3) patients with abnormal immune activation in vivo back to normal. Of course, also include immune reconstitution after antiretroviral therapy, a variety of AIDS-related opportunistic infections and decrease the incidence of tumors, AIDS patients to reduce mortality and morbidity. However, HAART therapy on immune reconstitution of AIDS also has its limitations: 1) HAART can not all AIDS patients the reconstruction of the immune function; 2) HAART can not be re-anti-HIV-specific CD4 + T lymphocyte immune response, CD8 + T lymphocytes the ability of specific anti-HIV has declined, which means that patients will be long-term maintenance medication.

Anti-HIV immune response


Anti-HIV immune responses, including specific immune and non-specific immune response to specific immune response to the main. Specific humoral immunity: HIV enters the body 2 to 12 weeks, the body's immune system protein that is produced for a variety of HIV-specific antibodies, and only one with antiviral antibody. Specific cell-mediated immunity: the main-specific CD4 + T lymphocyte immune response and specific cytotoxic T lymphocyte response (CTL).

CD4 + T lymphocytes in the immune system as a central cell in specific immunity plays an important role. Through the secretion of various cytokines to induce B cells to produce anti-HIV antibodies, and promote anti-HIV-specific CTL in the generation and maturation, activation of macrophages and NK cells. CD8 + T lymphocytes is a specific cell-mediated immune effector cell, directly or through the secretion of various cytokines (such as tumor necrosis factor, interferon, etc.), inhibit viral replication.

The course of HIV infection


1. Primary infection

Need to help HIV-susceptible cell surface receptor to enter cells, including the first and second receptor receptor. HIV-1 glycoprotein gp120 of the outer membrane with the first receptor-binding first, and then again with the second gp120 receptor binding, gp120 conformation change, separation and gp41, which eventually led to integration of HIV with host cell membranes to enter cells.

After HIV enters the human body in 24-48 hours to reach the local lymph nodes, about 5 days in the peripheral blood can detect the virus components. Then produce viremia, leading to acute infection.

2.HIV in human cells infected with the process of

Adsorption and penetration: HIV-1 infection in the human body, the selective adsorption of target cells in the CD4 receptor, in the help of co-receptor to enter host cells.

Central and integration: viral RNA in the role of reverse transcriptase to form cDNA, in the role of DNA polymerase to form double-stranded DNA, the role of the integrase, the newly formed non-covalent binding of double-stranded DNA into host cells DNA in chromosomes. This integration of double-stranded DNA virus that is, before the virus.

Transcription and translation: the former virus was carried out in self-activation of transcription, the virus DNA transcription, the formation of RNA, some RNA cap increases by the end of Canada to become the progeny virus genome RNA; other RNA virus by splicing into mRNA, protein in the cell body turn to the virus structural proteins and non-structural protein, viral protein synthesis, including ribosomal endoplasmic reticulum for glycosylation and processing, in the role of protease cleavage, resulting in progeny virus proteins and enzymes.

Assembly, and budding maturity: Gag virus RNA binding protein and assembly into the nuclear shell, through the budded from the cytoplasmic membrane when the virus body to release the capsule, the formation of mature virus particles.

After infection 3.HIV three clinical outcome

As the body's immune system can not be completely clear the virus, chronic infection can be clinically manifested as typical progressors, rapid progressors and long-term non-progressors three vesting. The impact of HIV infection of the main factors vesting virus, host immune and genetic backgrounds.

Clinical manifestations and stages of AIDS

From the initial to the end-stage HIV infection is a long complex process, in the process at different stages of HIV associated with a wide range of clinical manifestations. Established in 2001 with reference to "HIV / AIDS diagnostic criteria and treatment of the principle of" People's Republic of China national standard (for trial implementation), the whole process of AIDS is divided into the acute stage, asymptomatic period and the AIDS period.

(A) acute phase

Usually occurs in HIV infection after the initial 2-4 weeks. Part of the emergence of HIV infection viremia and immune system damage produced by acute clinical symptoms. A slight majority of patients with clinical symptoms, sustained remission after 1-3 weeks. Clinical manifestations to the most common fever can be accompanied by pharyngodynia, sweating, nausea, vomiting, diarrhea, rash, joint pain, swollen lymph nodes and nervous system symptoms.

This period could be detected in blood HIV-RNA and the P24 antigen, and HIV antibody in a few weeks after infection only. CD4 + T lymphocyte count had a reduction, at the same time can also be inverted CD4/CD8 ratio. Some patients may have mild reduction in white blood cell and platelet or liver dysfunction.

(B) asymptomatic period

From the acute phase in this period, with or without obvious symptoms of the acute phase and direct access to this period.

The duration of this period is generally 6-8 years. Its duration and the number of infected, type, infection, immune status of the individual differences, nutrition and other lifestyle conditions and factors. In the asymptomatic period in HIV-infected persons as a result of continuous replication in vivo, impaired immune system, CD4 + T lymphocyte count decreased, while infectious.

(C) a view of AIDS

For HIV infection in the final stage after. Patients with CD4 + T lymphocyte count decreased more <200/mm3, HIV plasma viral load increased significantly. The main clinical manifestations of this period for HIV-related symptoms, a variety of opportunistic infections and tumors.

HIV-related symptoms: mainly for the more than one month of continuous fever, sweating, diarrhea; more than 10% weight loss. Some patients showed neuropsychiatric symptoms such as memory, mental apathy, personality changes, headache, such as epilepsy and dementia. In addition there may also be persistent systemic lymph nodes, which is characterized by ①. The exception than the groin two or more parts of the lymph nodes; ②. Lymph node diameter ≥ 1 cm, no tenderness, no adhesions; ③. Continued time for more than 3 months.

Systems common opportunistic infections and tumors is as follows (see diagnosis of opportunistic infections common part).

Respiratory: Pneumocystis carinii pneumonia (PCP), tuberculosis, recurrent bacterial, fungal pneumonia.

Central nervous system: cryptococcal meningitis, tuberculous meningitis, toxoplasma encephalopathy, a variety of viral meningoencephalitis.

Digestive system: Candida albicans esophagitis and cytomegalovirus esophagitis, enteritis; Salmonella, Shigella, Campylobacter jejuni, and Cryptosporidium enteritis.

Oral: thrush, tongue, hairy leukoplakia, recurrent oral ulcers, gingivitis and other.

Skin: herpes zoster, molluscum contagiosum, condyloma, fungi and甲癣dermatitis.

Eye: Cytomegalovirus retinitis and Toxoplasma gondii.

Tumor: malignant lymphoma, such as Kaposi's sarcoma.

Note that AIDS was a view to the diversification of the clinical manifestations, complications are not the same, the local prevalence of diseases and is closely related to the prevalence rate.

Principles of diagnosis: HIV / AIDS diagnosis to be combined with epidemiological history (including the life history of unsafe sex, intravenous drug use history, type of anti-HIV antibody testing without blood or blood products, HIV-positive children born to or occupational exposure History, etc.), clinical manifestations and laboratory tests such as comprehensive analysis, careful to make the diagnosis. Diagnosis of HIV / AIDS must be HIV-positive (confirmed by the confirmatory test), and P24 antigen and HIV RNA detection help HIV / AIDS diagnosis, in particular antibodies can shorten the "window period" and to help the early diagnosis of neonatal HIV infection.

(A) acute phase

Diagnostic criteria: patient history of the near future epidemiological and clinical performance, combined with laboratory HIV antibodies can be from negative to positive diagnosis, or only by laboratory tests negative for antibodies to HIV-positive diagnosis can be.

(B) asymptomatic period

Diagnostic criteria: There are epidemiological history, can be combined with HIV-positive diagnosis, or laboratory tests to diagnose HIV-positive.

(C) a view of AIDS

(1) unexplained persistent irregular fever above 38 ℃,> 1 month

(2) the number of chronic diarrhea more than 3 times / day,> 1 month

(3) 6 months more than 10% weight loss

(4) recurrent oral Candida albicans infection

(5), recurrent herpes simplex virus infection or herpes zoster virus infection

(6) Pneumocystis carinii pneumonia (PCP)

(7) recurrent bacterial pneumonia

(8) active tuberculosis or Mycobacterium tuberculosis disease

(9) deep fungal infection

(10) central nervous system lesions

(11) dementia occur in young people

(12) of active cytomegalovirus infection

(13) Toxoplasma encephalopathy

(14) marneffei infection

(15) recurring sepsis

(16) mucocutaneous or visceral Kaposi's sarcoma, lymphoma

Diagnostic criteria: A History of epidemiology, laboratory tests HIV-positive, the above plus any one can be diagnosed as AIDS. Or HIV-positive, while the number of CD4 + T lymphocytes <200/mm3, can also be diagnosed as AIDS.

Common diagnosis and treatment of opportunistic infections and prevention

(A) Pneumocystis carinii pneumonia

1. Diagnosis:

(1) occult or subacute onset, dry cough, shortness of breath and after the increase, may have fever, cyanosis, respiratory distress occurred in severe cases; (2) the lungs less positive signs, or could be heard and a small amount of wet and dry bulk in La Music . Signs and symptoms of disease are often out of proportion to the severity of; (3) chest X-ray examination shows that the beginning of lungs from the hilar diffuse reticular nodular interstitial infiltration, and sometimes ground-glass-like shadow was; (4) hypoxia, blood gas analysis hyperlipidemia, serious cases of arterial partial pressure of oxygen (Pa02) significantly reduced, often below 60mmHg; (5) often increase in blood lactate dehydrogenase; (5) Inspection diagnosis rely on the etiology, such as sputum or bronchoalveolar lavage / found in lung tissue biopsy, such as Pneumocystis carinii cysts or trophozoites of.

2. Treatment:

(1) symptomatic treatment: bed rest, give oxygen and improve the ventilation function, attention to water and electrolyte balance. Such as dyspnea patients obviously, can be artificial ventilators. PCP in patients with severe (PaO2 <70mmHg or alveolar - arterial oxygen difference> 35mmHg, available 40mg prednisone orally 2 times a day 5 days, 2 to 20mg daily oral 5 days, 20mg daily oral 1 to the end of anti-PCP; such as intravenous methylprednisolone, prednisone dosage for 75% of the above. (2) Pathogen treatment: 9-12 of choice cotrimoxazole tablet / day (TMP daily 15mg/kg, SMZ daily 100mg/kg), oral, 3-4 times daily, 2-3 week course of treatment. cotrimoxazole injection (dose ibid.), each at 6-8h 1, intravenous infusion. replacement therapy: dapsone 100mg, oral, 1 day; trimethoprim combined with 200-400mg, oral, 2-3 times daily, 2-3 week course of treatment. or clindamycin 600-900mg, iv, every 6h 1 times, or 450mg orally every 6h 1 times; primaquine combined with 15-30mg, oral, 1 day, 2-3 week course of treatment. or Pentamidine ,3-4mg / kg, day 1, slow intravenous infusion ( more than 60 minutes), course of 2-3 weeks.

3. Prevention:

(1) prevention indications: CD4 + T lymphocyte count <200/mm3 and young adults, including pregnant women and acceptance of HAART treatment. (2) Drug choices: first choice cotrimoxazole, weight ≥ 60Kg, and 2 / day, body weight <60Kg, the one / day. If patients can not tolerate the drug, alternative drugs are dapsone and TMP. Patients suffering from PCP by HAART therapy increased CD4 + T lymphocytes> 200/mm3 and sustained ≥ 6 months, to stop drug use prevention. If the CD4 + T lymphocyte count has decreased to <200/mm3 should be re-started the prevention of drug use.

(B) TB

1. Diagnosis

Confirmed that the activities of clinical tuberculosis.

2. Treatment

Once the concurrent HIV-positive TB patients, the treatment with conventional anti-TB treatment, but treatment should be extended. Should pay attention to the use of anti-tuberculosis drugs and anti-viral drugs and the interaction between the incompatibility.

Drugs: isoniazid (H), amikacin (A), rifampicin (R), rifapentine (L), ethambutol (E), sodium p-aminosalicylic acid (PAS) , pyrazinamide (Z) and streptomycin (S).

Drug dosage, usage, and the major toxicity in the table below

The name of the drug
  Daily therapy
  Intermittent therapy

Adults (g)

(Week 1-2 times)

 
  The main adverse reactions
 
Adults (g)
  Children

Mg / kg
 
<50kg
  ≥ 50kg
  <50kg
  ≥ 50kg
 
H
  0.3
  0.3
  10-15
  0.5
  0.6
  Liver toxicity, peripheral neuritis
 
S
  0.75
  0.75
  20-30
  0.75
  0.75
  Hearing impairment, renal dysfunction, allergic reactions
 
R
  0.45
  0.6
  10-20
  0.6
  0.6
  Liver toxicity, gastrointestinal reactions, allergic reactions
 
E
  0.75
  1.0
  --
  1.0-1.2
  1.0-1.2
  Visual impairment, narrow field of vision
 
PAS
  8.0
  8.0
  150-250
  10
  12
  Liver toxicity, gastrointestinal reactions, allergic reactions
 
Z
  1.5
  1.5
  30-40
  2.0
  2.0
  Liver toxicity, gastrointestinal reactions, gout
 
L
  
  
  
  0.6
  0.6
  With rifampin
 


     Chemotherapy program (listed in the beginning of two common chemotherapy administration are as follows, more treatment options, see the national tuberculosis control guidelines):

① 2HRZE / 4HR: strengthening period: twelve months, H, R, Z, E, once a day; continue Duration: four months, H, R once a day. ② 2H3 R3 Z3 E3 / 4H3 R3: strengthen the period: two months, H, R, Z, E, the next day once; continue Duration: four months, H, R, the first day.

3. Prevention

Indications: AIDS patients with tuberculosis is not necessary to the prevention of chemical drugs, but clinicians can refer to the following advice for preventive chemotherapy: patients with CD4 + T lymphocyte count <200/mm3, they can carry out preventive chemotherapy, and its programs are: ① rifapentine + isoniazid, take 4-6 consecutive months (dosage see table above). ② Isoniazid, continuous use of 12 months (dosage see table above).

(C) infected with Mycobacterium

1. Diagnosis

Mycobacterium infection in clinical symptoms similar to those with active disease, but systemic change for the common sexually transmitted diseases spread. Diagnosis: blood culture, sputum culture, lung biopsy, bronchial washing sputum of non-material culture of Mycobacterium tuberculosis.

2. Treatment

Other treatment with Mycobacterium tuberculosis.

Mycobacterium Bird (MAC) therapy: treatment of choice: clarithromycin 500 mg / time, 2 times / day or (azithromycin toxin 600mg / day) + ethambutol 15 mg / kg / day (sub-sub-services), critically ill patients can be combined with Rifabutin (300-600 mg / day) or amikacin (10 mg / kg / times by intramuscular injection, 1 times / day), treatment for 6 months. Replacement therapy program: Rifabutin (300-600 mg / day) + amikacin (10 mg / kg / times by intramuscular injection, 1 times / day) + ciprofloxacin (750 mg / time, 2 times / days), treatment for 6 months.

3. Prevention

AIDS patients are not to be of non-tuberculous mycobacterial disease prevention for chemical drugs, doctors can refer to the following based on clinical opinion. AIDS patients, when the CD4 + T lymphocytes <50/mm3 may prophylactic treatment in order to minimize the chance of disseminated MAC. Is clarithromycin 500mg / times, 2 times / day; or Azithromycin, 1200mg / week. If a patient is treated by HAART so that increased CD4 + T lymphocytes> 100/mm3 and sustained ≥ 6 months, to stop drug use prevention.

(D) cytomegalovirus retinal choroiditis

1. Diagnosis

The performance of clinical common vision for the rapid decline in fundus diagnosis depends on microscopic examination.

2. Treatment

(1) Ganciclovir 5mg/kg / day, divided into 2 intravenous ,2-3 weeks later renamed 5mg/kg / day, day 1, intravenous infusion, to maintain life. Can cause neutropenia, thrombocytopenia and renal insufficiency. In a critical condition or a single drug therapy may be combined with intravenous infusion of foscarnet 90mg/kg, 2 times daily. If retinitis also retrobulbar injection of ganciclovir.

(2) intravenous infusion of foscarnet 90mg/kg, 2 times daily, 2-3 weeks after the application changed to long-term intravenous infusion of 90mg/kg per day 1 times, can lead to renal failure, nausea, and electrolyte imbalance, if the creatinine clearance rate of abnormal, then adjust the dose.

3. Prevention

For CD4 + T lymphocyte count <200/mm3 of AIDS patients should have regular eye checks. If CMV disease, should be actively treated disease control in the after life-long medication required to prevent recurrence. For CD4 + T lymphocyte count <50/mm3 of AIDS patients should be given to the prevention of conventional medication (oral ganciclovir), effective in the treatment of patients with HAART if their CD4 + T lymphocyte count> 100/mm3 continued in June and more than can be given to stopping the prevention of drug delivery.

(E) toxoplasma encephalopathy

1. Diagnosis

Toxoplasma encephalopathy often occurred in CD4 + T lymphocyte count <100 / mm3 patients. Manifested as focal or diffuse central nervous system impairment, headache, low fever, drowsiness, restlessness and drowsiness, focal symptoms, including epilepsy and stroke. Other symptoms include: double vision,偏盲, blindness, ataxia, myoclonus, fibrillation, personality changes, hallucinations and syncope. Meningitis is not common. Head CT for one or more low-density lesions, CT-like ring or nodular enhancement. Head MRI is more sensitive than CT, MRI showed the typical multiple intracranial long T1 and long T2 signal. Diagnosis relies on brain biopsy.

2. Treatment

Preferred treatment: pyrimethamine (loading dose 100mg, orally, 2 times / day, then 50-75mg / day to maintain) + sulfadiazine (1-1.5g, orally, 4 times / day), the general course of treatment for three weeks, with severe patients and the clinical, imaging to improve the patients are not satisfied with the treatment could be extended to more than six weeks. Can not be tolerated and will be able to choose sulfa allergy clindamycin 600mg / time, intravenous administration, every administration of the first six hours, the Joint pyrimethamine. Blood system in order to reduce adverse reactions, co-folinic acid 10-20mg / day.

3. Prevention

History of non-Toxoplasma encephalopathy but CD4 + T cell count <100/mm3 and gondii IgG antibody-positive patients should be routine use of cotrimoxazole 2 / day to prevent, for the past suffered from Toxoplasma encephalopathy patients to long-term with pyrimethamine (25-50mg / day) + sulfadiazine joint (2-4g / day) to prevent. HAART treatment of patients with CD4 + T cells make to> 200/mm3 and sustained ≥ 3-6 months, to stop drug use prevention. Antibodies to Toxoplasma gondii negative and CD4 + T cell count <100/mm3 should be avoided in patients infected with Toxoplasma gondii. Specific measures include: meat food should be frozen in -20 ℃; meat cooked food (at least more than 60 ℃) in order to kill tissue cysts; to wash fruits and vegetables; do not a Pet.

(F) fungal infections

1. Diagnosis

Clinical diagnosis of fungal infection, Candida infection is common and cryptococcal infection.

2. Treatment

(1) Candida infection

Oral candidiasis is the first choice for the treatment of partial smear plus nystatin mouthwash mouthwash of sodium bicarbonate, if no response to the above treatment, the treatment can be given as follows: fluconazole: 50mg-100mg / times, oral, 1 times / day , course of 1-2 weeks. Esophageal candidiasis: the first dose of fluconazole 200mg / day, later changed to 100mg / time, 1 times / day, applied 1-2 weeks; increase the dose of fluconazole in critically ill patients and prolong the course of treatment. Candida infection of the proposed recurrent Fluconazole 100mg / day, long-term use.

(2), cryptococcal meningitis

1) The intracranial pressure lowering treatment: the first choice of mannitol, severe lateral drainage are feasible.

2) anti-fungal treatment: the first choice of amphotericin B, first day 1mg, 5% glucose 500ml water slowly static points (should not use normal saline, to be dark), no less than 6-8 hours of infusion. For the second and third days of the 2 mg and 5 mg, by adding glucose 500ml water drip. The fourth day of the absence of reaction can increase to 10mg. If there are no serious response, then later by 5mg / day increase in general up to 30-40 mg (maximum dose 50mg / day). Treatment needs of more than 3 months, the total amphotericin B dose of 2-4g. Adverse effects of amphotericin B greater need close observation. Amphotericin B and 5 - fluorocytosine (5FC) combined with synergy. 5FC to 100mg/kg / day (1.5g-2.0g, 3 / day), the two shared at least 8-12 weeks. Amphotericin B and fluconazole may also be joint use, use for fluconazole 200mg / day, oral or intravenous infusion, 8-12 week course of treatment.

3) if necessary, by the intraventricular injection tube amphotericin B 0.5-1mg / times a day.

4) can be used in stable condition after the maintenance fluconazole, 200mg / time, 1 times / day, the long-term maintenance to prevent recurrence.