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| {{CMG}} | | {{CMG}} |
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| ==Overview== | | ==Overview== |
| '''Acquired immune deficiency syndrome '''('''AIDS''') is a [[syndrome|collection of symptoms and infections]] resulting from the specific damage to the [[immune system]] caused by the [[HIV|human immunodeficiency virus]] (HIV) in humans,<ref>{{cite web
| | Acute HIV should be suspected in patients with flu-like or mononucleosis-like symptoms within 2-4 weeks of exposure to HIV virus or participation in high risk behaviors. Important historical questions for patients with diagnosed HIV/AIDS include: most recent CD4 count and viral load and date of testing, previous and current ART regimens and adherence to treatment, prior drug-resistance testing, current antibiotic prophylaxis, and history of AIDS-defining illnesses. Although a significant proportion of patients are asymptomatic, those who manifest an acute illness present with fever, lymphadenopathy, rash, fatigue, and myalgia. This stage is usually followed by a clinical latency period throughout which patients may not experience any symptoms. AIDS defines the final stage of HIV infection and indicates significant immune compromise. AIDS classically presents with weight loss, night sweats, fatigue, and symptoms of opportunistic infections (or AIDS-defining illnesses) such as diarrhea, mucosal sores, cough, and cognitive and neurological deficits. |
| |url=http://www.niaid.nih.gov/Publications/hivaids/hivaids.htm
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| |title=The Relationship Between the Human Immunodeficiency Virus and the Acquired Immunodeficiency Syndrome |publisher= NIAID
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| |accessdate=2008-03-10}}</ref> and similar viruses in other species ([[Simian immunodeficiency virus|SIV]], [[Feline immunodeficiency virus|FIV]], etc.).
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| ==History and Symptoms== | | ==History== |
| | * AIDS should be suspected in patients with flu-like or mononucelosis-like symptoms within 2-4 weeks of exposure to HIV virus or participation in high risk behaviors. |
| | * History of exposures and possible risk factors is important in all patients presenting with such a syndrome. |
| | * For patients with diagnosed and treated HIV/AIDS, important questions include: most recent CD4 count and viral load and date of testing, previous and current ART regimens and adherence to treatment, prior drug-resistance testing, and history of AIDS-defining illnesses. |
| | * In patients admitted for AIDS-related infections, a careful history of infectious exposures is required that includes travel history, exposure to sick individuals, exposure to pets or animals, and current antibiotic prophylaxis. |
| | * History of co-infections such as hepatitis B and C and tuberculosis are also relevant. |
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| [[Image:Hiv-timecourse.png|450px|thumb|left|A generalized graph of the relationship between HIV copies (viral load) and CD4 counts over the average course of untreated HIV infection; any particular individual's disease course may vary considerably.
| | ==Symptoms== |
| {{legend-line|blue solid 2px|CD4<sup>+</sup> T Lymphocyte count (cells/mm³)}}
| | ===Acute Retroviral Syndrome=== |
| {{legend-line|red solid 2px|HIV RNA copies per mL of plasma}}
| | *Within 2-4 weeks after HIV infection, patients may complain of flu-like or mononucleosis-like symptoms. This phase is known as the acute retroviral syndrome. The common symptoms include: |
| ]] | | :*[[Fever]] |
| | :*[[Lymphadenopathy]] |
| | :*[[Rash]] |
| | :*[[Fatigue]] |
| | :*[[Myalgia]] |
| | :*Arthritic pain |
| | :*[[Headache]] |
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| The symptoms of AIDS are primarily the result of conditions that do not normally develop in individuals with healthy [[immune system]]s. Most of these conditions are infections caused by [[bacteria]], [[virus]]es, [[fungus|fungi]] and [[parasite]]s that are normally controlled by the elements of the immune system that HIV damages. [[Opportunistic infection]]s are common in people with AIDS.<ref name=Holmes>{{ | | ===Clinical Latency Stage=== |
| | The acute or asymptomatic phase is followed by a clinical latency period throughout which patients may not experience any symptoms. The virus can be detected at this stage and patients are able to transmit the disease. |
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| cite journal
| | ===AIDS=== |
| | author=Holmes CB, Losina E, Walensky RP, Yazdanpanah Y, Freedberg KA
| | Symptoms can include the following. |
| | title=Review of human immunodeficiency virus type 1-related opportunistic infections in sub-Saharan Africa
| | :*Rapid [[weight loss]] |
| | journal=Clin. Infect. Dis. | year=2003 | pages=656–662 | volume=36 | issue=5
| | :*Recurring [[fever]] or profuse [[night sweats]] |
| | pmid=12594648
| | :*Extreme and unexplained fatigue |
| | :*Prolonged [[lymphadenopathy]] |
| | :*[[Memory loss]], [[depression]] and other neurological disorders |
| | :*Symptoms of opportunistic infections (See below) |
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| }}</ref> HIV affects nearly every [[organ system]]. People with AIDS also have an increased risk of developing various cancers such as [[Kaposi's sarcoma]], [[cervical cancer]] and cancers of the immune system known as [[lymphoma]]s.
| | ==Symptoms of Opportunistic Infections== |
| | Opportunistic infections can produce a wide variety of symptoms that can often unmask AIDS in patients without previously documented HIV infection. These infections are known as AIDS-defining illnesses. |
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| Additionally, people with AIDS often have systemic symptoms of infection like [[fever]]s, [[sweat]]s (particularly at night), swollen glands, chills, weakness, and [[weight loss]].<ref name=Guss>{{
| | ===Pulmonary Infections=== |
| | * '''Cough''' |
| | :* Dry: Suggestive of ''Pneumocystis jirovecii'' pneumonia |
| | :* Productive: Suggestive of bacterial or fungal pneumonia |
| | * '''Hemoptysis''' |
| | :* Suggestive of tuberculosis or fungal pneumonia |
| | * '''Dyspnea''' |
| | * '''Chest pain''' |
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| cite journal
| | ===Gastrointestinal Infections=== |
| | author=Guss DA
| | * '''Chest pain''' |
| | title=The acquired immune deficiency syndrome: an overview for the emergency physician, Part 1
| | :* Suggestive of esophageal candidiasis |
| | journal=J. Emerg. Med. | year=1994 | pages=375–384 | volume=12 | issue=3
| | * '''Abdominal pain''' |
| | pmid=8040596
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| }}</ref><ref name=Guss2>{{
| | :* Suggestive of bacterial gastroenteritis, [[cytomegalovirus]] (CMV) [[colitis]], or ''[[Clostridium difficile]]'' colitis |
| | * '''Chronic diarrhea''' |
| | :* Suggestive of [[cryptosporidiosis]], [[cytomegalovirus]] (CMV) [[colitis]], or ''[[Clostridium difficile]]'' colitis |
| | * '''Bloody diarrhea''' |
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| cite journal
| | :* Suggestive of invasive bacterial gastroenteritis, [[cytomegalovirus]] (CMV) [[colitis]] or ''[[Clostridium difficile]]'' colitis |
| | author=Guss DA
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| | title=The acquired immune deficiency syndrome: an overview for the emergency physician, Part 2
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| | journal=J. Emerg. Med. | year=1994 | pages=491–497 | volume=12 | issue=4
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| | pmid=7963396
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| }}</ref> After the diagnosis of AIDS is made, the current average survival time with antiretroviral therapy (as of 2005) is estimated to be more than 5 years,<ref name=Schneider>{{
| | ===Neurological Disease=== |
| | * '''Focal neurological deficits''' |
| | :* Suggestive of cerebral [[toxoplasmosis]], [[Progressive multifocal leukoencephalopathy]] (PML), primary CNS lymphoma, or disseminated TC or MAC |
| | * '''Memory loss and cognitive decline''' |
| | :* Suggestive of AIDS-Dementia complex or primary CNS lymphoma |
| | * '''Fever, headache, meningeal signs and symptoms''' |
| | :* Suggestive of meningitis, consider cryptococcal meningitis |
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| cite journal
| | ===Skin and Mucosal Disease=== |
| | author=Schneider MF, Gange SJ, Williams CM, Anastos K, Greenblatt RM, Kingsley L, Detels R, Munoz A
| | * '''Purpulish rash that responds poorly to treatment''' |
| | title=Patterns of the hazard of death after AIDS through the evolution of antiretroviral therapy: 1984–2004
| | :* Suggestive of [[Kaposi's sarcoma]] or [[bacillary angiomatosis]] |
| | journal=AIDS | year=2005 | pages=2009–2018 | volume=19 | issue=17
| | * '''Massive lymphadenopathy''' |
| | pmid=16260908
| | :* Suggestive of malignant lymphoma |
| | * '''Mucosal leasions that respond poorly to treatment''' |
| | :* Suggestive of HPV related tumors (Oral/Anal squamous cell carcinoma, invasive cervical cancer) |
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| }}</ref> but because new treatments continue to be developed and because HIV continues to [[Evolution|evolve]] resistance to treatments, estimates of survival time are likely to continue to change. Without antiretroviral therapy, death normally occurs within a year. Most patients die from opportunistic infections or [[malignancies]] associated with the progressive failure of the immune system.<ref name=Lawn>{{
| | ===Systemic Disease=== |
| | * '''Weight loss, night sweats, excessive fever''' |
| | :* Suggestive of disseminated MAC, TB, or lymphoma |
| | :* May also be related to HIV itself |
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| cite journal
| | ===Other manifestations=== |
| | author=Lawn SD
| | * '''Blurry vision or vision loss''' |
| | title=AIDS in Africa: the impact of coinfections on the pathogenesis of HIV-1 infection
| | :* Suggestive of CMV retinitis |
| | journal=J. Infect. Dis. | year=2004 | pages=1–12 | volume=48 | issue=1
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| | pmid=14667787
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| }}</ref>
| | ==References== |
| | | {{reflist|2}} |
| The rate of clinical disease progression varies widely between individuals and has been shown to be affected by many factors such as host susceptibility and immune function health care and co-infections,<ref name=Lawn /> as well as factors relating to the viral strain.<ref name=Campbell2>{{
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| cite journal
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| | author=Campbell GR, Watkins JD, Esquieu D, Pasquier E, Loret EP, Spector SA
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| | title=The C terminus of HIV-1 Tat modulates the extent of CD178-mediated apoptosis of T cells
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| | journal=J. Biol. Chem. | year=2005 | pages=38376–39382 | volume=280 | issue=46
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| | pmid=16155003
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| }}</ref><ref name=Senkaali>{{
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| cite journal
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| | author=Senkaali D, Muwonge R, Morgan D, Yirrell D, Whitworth J, Kaleebu P
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| | title=The relationship between HIV type 1 disease progression and V3 serotype in a rural Ugandan cohort
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| | journal=AIDS Res. Hum. Retroviruses. | year=2005 | pages=932–937 | volume=20 | issue=9
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| | pmid=15585080
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| }}</ref> The specific opportunistic infections that AIDS patients develop depend in part on the prevalence of these infections in the geographic area in which the patient lives.
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| ===Pulmonary infections===
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| [[Image:PCPxray.jpg|thumb|left|150px|X-ray of [[Pneumocystis pneumonia (PCP)|''Pneumocystis jirovecii'']] caused pneumonia. There is increased white (opacity) in the lower lungs on both sides, characteristic of ''Pneumocystis'' pneumonia]]
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| [[Pneumocystis pneumonia (PCP)|Pneumocystis pneumonia]] (originally known as ''Pneumocystis carinii'' pneumonia, and still abbreviated as PCP, which now stands for '''P'''neumo'''c'''ystis '''p'''neumonia) is relatively rare in healthy, [[immunocompetent]] people, but common among HIV-infected individuals. It is caused by [[Pneumocystis pneumonia (PCP)|''Pneumocystis jirovecii'']]. Before the advent of effective diagnosis, treatment and routine [[prophylaxis]] in Western countries, it was a common immediate cause of death. In developing countries, it is still one of the first indications of AIDS in untested individuals, although it does not generally occur unless the CD4 count is less than 200 per µL.<ref name=Feldman>{{
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| cite journal
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| | author=Feldman C | title=Pneumonia associated with HIV infection
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| | journal=Curr. Opin. Infect. Dis. | year=2005 | pages=165–170 | volume=18 | issue=2
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| | pmid=15735422
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| }}</ref>
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| [[Tuberculosis]] (TB) is unique among infections associated with HIV because it is transmissible to immunocompetent people via the respiratory route, is easily treatable once identified, may occur in early-stage HIV disease, and is preventable with drug therapy. However, [[multidrug resistance]] is a potentially serious problem. Even though its incidence has declined because of the use of directly observed therapy and other improved practices in Western countries, this is not the case in developing countries where HIV is most prevalent. In early-stage HIV infection (CD4 count >300 cells per µL), TB typically presents as a pulmonary disease. In advanced HIV infection, TB often presents atypically with extrapulmonary (systemic) disease a common feature. Symptoms are usually constitutional and are not localized to one particular site, often affecting [[bone marrow]], [[bone]], urinary and [[gastrointestinal tract]]s, [[liver]], regional [[lymph node]]s, and the [[central nervous system]].<ref name=Decker>{{
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| cite journal
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| | author=Decker CF, Lazarus A
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| | title=Tuberculosis and HIV infection. How to safely treat both disorders concurrently
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| | journal=Postgrad Med. | year=2000 | pages=57–60, 65–68 | volume=108 | issue=2
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| | pmid=10951746
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| }}</ref>
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| ===Gastrointestinal infections===
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| [[Esophagitis]] is an inflammation of the lining of the lower end of the [[esophagus]] (gullet or swallowing tube leading to the [[stomach]]). In HIV infected individuals, this is normally due to fungal ([[candidiasis]]) or viral ([[Herpes simplex virus|herpes simplex-1]] or [[cytomegalovirus]]) infections. In rare cases, it could be due to [[mycobacteria]].<ref name=Zaidi>{{
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| cite journal
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| | author=Zaidi SA, Cervia JS
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| | title=Diagnosis and management of infectious esophagitis associated with human immunodeficiency virus infection
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| | journal=J. Int. Assoc. Physicians AIDS Care (Chic Ill) | year=2002 | pages=53–62 | volume=1 | issue=2
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| | pmid=12942677
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| }}</ref> | |
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| Unexplained chronic [[diarrhea]] in HIV infection is due to many possible causes, including common bacterial (''[[Salmonella]]'', ''[[Shigella]]'', ''[[Listeria]]'', ''[[Campylobacter]]'', or ''[[Escherichia coli]]'') and parasitic infections; and uncommon opportunistic infections such as [[cryptosporidiosis]], [[microsporidiosis]], ''[[Mycobacterium avium]]'' complex (MAC) and [[cytomegalovirus]] (CMV) [[colitis]]. In some cases, diarrhea may be a side effect of several drugs used to treat HIV, or it may simply accompany HIV infection, particularly during primary HIV infection. It may also be a side effect of [[antibiotic]]s used to treat bacterial causes of diarrhea (common for ''[[Clostridium difficile]]''). In the later stages of HIV infection, diarrhea is thought to be a reflection of changes in the way the [[intestinal tract]] absorbs nutrients, and may be an important component of HIV-related [[wasting]].<ref name=Guerrant>{{
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| cite journal
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| | author=Guerrant RL, Hughes JM, Lima NL, Crane J
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| | title=Diarrhea in developed and developing countries: magnitude, special settings, and etiologies
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| | journal=Rev. Infect. Dis. | year=1990 | pages=S41–S50 | volume=12 | issue=Suppl 1
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| | pmid=2406855
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| }}</ref>
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| ===Neurological diseases===
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| [[Toxoplasmosis]] is a disease caused by the single-celled [[parasite]] called ''Toxoplasma gondii''; it usually infects the brain causing toxoplasma [[encephalitis]] but it can infect and cause disease in the [[eye]]s and lungs.<ref name=Luft>{{
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| cite journal
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| | author=Luft BJ, Chua A
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| | title=Central Nervous System Toxoplasmosis in HIV Pathogenesis, Diagnosis, and Therapy
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| | journal=Curr. Infect. Dis. Rep. | year=2000 | pages=358–362 | volume=2 | issue=4
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| | pmid=11095878
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| }}</ref> | | {{WH}} |
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| [[Progressive multifocal leukoencephalopathy]] (PML) is a [[demyelinating disease]], in which the gradual destruction of the [[myelin]] sheath covering the [[axon]]s of nerve cells impairs the transmission of nerve impulses. It is caused by a virus called [[JC virus]] which occurs in 70% of the population in [[Virus latency|latent]] form, causing disease only when the immune system has been severely weakened, as is the case for AIDS patients. It progresses rapidly, usually causing death within months of diagnosis.<ref name=Sadler>{{ | | [[Category:HIV/AIDS]] |
| | | [[Category:Disease]] |
| cite journal
| | [[Category:Immune system disorders]] |
| | author=Sadler M, Nelson MR
| | [[Category:Viral diseases]] |
| | title=Progressive multifocal leukoencephalopathy in HIV
| | [[Category:Pandemics]] |
| | journal=Int. J. STD AIDS | year=1997 | pages=351–357 | volume=8 | issue=6
| | [[Category:Sexually transmitted infections]] |
| | pmid=9179644
| | [[Category:Syndromes]] |
| | | [[Category:Virology]] |
| }}</ref>
| | [[Category:AIDS origin hypotheses]] |
| [[AIDS dementia complex]] (ADC) is a metabolic [[encephalopathy]] induced by HIV infection and fueled by immune activation of HIV infected brain [[macrophage]]s and [[microglia]] which secrete [[neurotoxin]]s of both host and viral origin.<ref name=Gray>{{
| | [[Category:Medical disasters]] |
| | | [[Category:Immunodeficiency]] |
| cite journal
| | [[Category:Microbiology]] |
| | author=Gray F, Adle-Biassette H, Chrétien F, Lorin de la Grandmaison G, Force G, Keohane C
| | [[Category:Emergency mdicine]] |
| | title=Neuropathology and neurodegeneration in human immunodeficiency virus infection. Pathogenesis of HIV-induced lesions of the brain, correlations with HIV-associated disorders and modifications according to treatments
| | [[Category:Up-To-Date]] |
| | journal=Clin. Neuropathol. | year=2001 | pages=146–155 | volume=20 | issue=4
| | [[Category:Infectious disease]] |
| | pmid=11495003
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| }}</ref> Specific neurological impairments are manifested by cognitive, behavioral, and motor abnormalities that occur after years of HIV infection and is associated with low CD4<SUP>+</SUP> T cell levels and high plasma viral loads. Prevalence is 10–20% in Western countries<ref name=Grant>{{
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| cite book
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| | author = Grant I, Sacktor H, McArthur J
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| | year = 2005
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| | title = The Neurology of AIDS
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| | chapter = HIV neurocognitive disorders
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| | chapterurl = http://www.hnrc.ucsd.edu/publications_pdf/2005grant1.pdf
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| | editor = H. E. Gendelman, I. Grant, I. Everall, S. A. Lipton, and S. Swindells. (ed.)
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| | edition = 2nd
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| | pages = 357–373
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| | publisher = Oxford University Press
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| | location = London, UK
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| | format= PDF
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| | id = ISBN 0-19-852610-5
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| }}</ref> but only 1–2% of HIV infections in India.<ref name=Satischandra>{{
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| cite journal
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| | author=Satishchandra P, Nalini A, Gourie-Devi M, et al | title=Profile of neurologic disorders associated with HIV/AIDS from Bangalore, South India (1989–1996)
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| | journal=Indian J. Med. Res. | year=2000 | pages=14–23 | volume=11 | issue=
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| | pmid=10793489
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| }}</ref><ref name=Wadia>{{
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| cite journal
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| | author=Wadia RS, Pujari SN, Kothari S, Udhar M, Kulkarni S, Bhagat S, Nanivadekar A
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| | title=Neurological manifestations of HIV disease
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| | journal=J. Assoc. Physicians India | year=2001 | pages=343–348 | volume=49 | issue=
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| | pmid=11291974
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| }}</ref> This difference is possibly due to the HIV subtype in India.
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| Cryptococcal meningitis is an infection of the [[meninges|meninx]] (the membrane covering the brain and [[spinal cord]]) by the fungus ''[[Cryptococcus]] neoformans''. It can cause fevers, [[headache]], [[Fatigue (medical)|fatigue]], [[nausea]], and [[vomiting]]. Patients may also develop [[seizure]]s and confusion; left untreated, it can be lethal.
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| ===Tumors and malignancies===
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| [[Image:Kaposi's Sarcoma.jpg|thumb|left|150px|Kaposi's sarcoma]] | |
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| Patients with HIV infection have substantially increased incidence of several malignant [[cancer]]s. This is primarily due to co-infection with an [[oncogene|oncogenic]] [[DNA virus]], especially [[Epstein-Barr virus]] (EBV), Kaposi's sarcoma-associated herpesvirus ([[KSHV]]), and human [[papillomavirus]] (HPV).<ref name=Boshoff>{{
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| cite journal
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| | author=Boshoff C, Weiss R
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| | title=AIDS-related malignancies
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| | journal=Nat. Rev. Cancer | year=2002 | pages=373–382 | volume=2 | issue=5
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| | pmid=12044013
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| }}</ref><ref name=Yarchoan>{{
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| cite journal
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| | author=Yarchoan R, Tosatom G, Littlem RF
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| | title=Therapy insight: AIDS-related malignancies — the influence of antiviral therapy on pathogenesis and management
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| | journal=Nat. Clin. Pract. Oncol. | year=2005 | pages=406–415 | volume=2 | issue=8
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| | pmid=16130937
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| }}</ref>
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| Kaposi's sarcoma (KS) is the most common tumor in HIV-infected patients. The appearance of this tumor in young homosexual men in 1981 was one of the first signals of the AIDS epidemic. Caused by a [[Gammaherpesvirinae|gammaherpes]] virus called [[Kaposi's sarcoma-associated herpes virus]] (KSHV), it often appears as purplish [[Nodule (medicine)|nodules]] on the skin, but can affect other organs, especially the [[mouth]], gastrointestinal tract, and lungs.
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| High-grade [[B cell]] [[lymphoma]]s such as [[Burkitt's lymphoma]], Burkitt's-like lymphoma, diffuse large B-cell lymphoma (DLBCL), and [[primary central nervous system lymphoma]] present more often in HIV-infected patients. These particular cancers often foreshadow a poor prognosis. In some cases these lymphomas are AIDS-defining. [[Epstein-Barr virus]] (EBV) or KSHV cause many of these lymphomas.
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| [[Cervical cancer]] in HIV-infected women is considered AIDS-defining. It is caused by [[human papillomavirus]] (HPV).<ref>{{cite journal | |
| |author=Palefsky J
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| |title=Human papillomavirus infection in HIV-infected persons
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| |journal=Top HIV Med
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| |volume=15
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| |issue=4
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| |pages=130–3
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| |year=2007
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| |pmid=17720998
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| |doi=
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| }}</ref>
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| In addition to the AIDS-defining tumors listed above, HIV-infected patients are at increased risk of certain other tumors, such as [[Hodgkin's disease]] and [[Anal cancer|anal]] and [[rectal carcinoma]]s. However, the incidence of many common tumors, such as [[breast cancer]] or [[colon cancer]], does not increase in HIV-infected patients. In areas where [[HAART]] is extensively used to treat AIDS, the incidence of many AIDS-related malignancies has decreased, but at the same time malignant cancers overall have become the most common cause of death of HIV-infected patients.<ref name=Bonnet>{{
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| cite journal
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| | author=Bonnet F, Lewden C, May T, et al | title=Malignancy-related causes of death in human immunodeficiency virus-infected patients in the era of highly active antiretroviral therapy
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| | journal=Cancer | year=2004 | pages=317–324 | volume=101 | issue=2
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| | pmid=15241829
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| }}</ref>
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| ===Other opportunistic infections===
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| AIDS patients often develop opportunistic infections that present with non-specific symptoms, especially [[low-grade fever]]s and weight loss. These include infection with ''[[Mycobacterium avium]]-intracellulare'' and [[cytomegalovirus]] (CMV). CMV can cause colitis, as described above, and [[Cytomegalovirus retinitis|CMV retinitis]] can cause [[blindness]]. [[Penicilliosis]] due to ''[[Penicillium marneffei]]'' is now the third most common opportunistic infection (after extrapulmonary tuberculosis and [[cryptococcosis]]) in HIV-positive individuals within the endemic area of Southeast Asia.<ref name=Skoulidis>{{
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| cite journal
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| | author=Skoulidis F, Morgan MS, MacLeod KM
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| | title=Penicillium marneffei: a pathogen on our doorstep?
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| | journal=J. R. Soc. Med.| year=2004 | pages=394–396 | volume=97 | issue=2
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| | pmid=15286196
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| }}</ref>
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| ==References==
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| {{reflist|2}}
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