Clinical manifestations and outcome of patients with human immunodeficiency virus infection at tertiary care teaching hospital.

BACKGROUND: AIDS has become chronic illness which is well treated with antiretroviral therapy and management of opportunistic infections (OIs). AIMS AND
OBJECTIVES: The study clinical profile and outcome of human immunodeficiency virus (HIV) seropositive patients.
MATERIALS AND METHODS: This was retrospective observational study carried out over a period of 1 year (January 2011-December 2011). All HIV patients admitted in medicine ward, and ICU were enrolled. Statistical analysis was performed using SSPE statistical software trial version 11. The P< 0.05 was considered as statistically significant.
RESULTS: Of total 111 patients with a diagnosis of HIV/AIDS, 75 (67.56%) were male and 36 (32.43%) were female patients. A total 52 (46.84%) patients presented with respiratory manifestations, of them 23 (44.23%) had pulmonary tuberculosis (TB), 6 (11.53%) had tubercular effusion, and 3 (5.76%) had Pneumocystis jirovecii pneumonia. Respiratory manifestations including pulmonary TB were the most common presentation (P< 0.001). Total 27 (24.32%) patients were presented with the neurological manifestation of them 8 (29.62%) had a cerebro-vascular accident, 5 (18.51%) had cryptococcal meningitis, 4 (14.81%) had tubercular meningitis, and 1 (3.70%) had progressive multifocal leukoencephalopathy. Total 12 (38.70%) had acute gastroenteritis 6 (19.35%) had oral candidiasis, 8 (25%) had general tonic clonic seizure and 7 (21.87%) had pyrexia of unknown origin, 6 (18.75%) had septicemia, 6 (18.75%) had acute renal failure, and 6 (94.11%) had anemia. A total 11 (9.90%) patients succumbed.
CONCLUSIONS: Overall respiratory manifestations were the common presentation in a present cohort of HIV seropositive patients and TB was the most common OI and the cerebrovascular accident was the most common neurological manifestation.

INTRODUCTION

The first case of AIDS in India was reported in 1986. Subsequently, a surveillance system was developed in 1987. India is estimated to have an adult (15–49 years) human immunodeficiency virus (HIV) prevalence of 0.27% in 2011. Adult HIV prevalence among males and females is estimated at 0.32% and 0.22%, respectively. According to the National AIDS Control Organisation (NACO) HIV cases in India are declining.[1] The adult HIV prevalence at national level has continued its steady decline from estimated level of 0.41% in 2001 through 0.35% in 2006–0.27% in 2011. Approximately, 61% male and 39% female people are living with HIV. The adult HIV prevalence rate in Maharashtra shows a declining trend from 1.08% in 2002 to 0.67% in 2007. The total estimated number of HIV positive persons is around 4.62 lakh, which accounts for 20% of the total estimated HIV-infected persons in the country and second highest after Andhra Pradesh. Approximately, 172,000 people died of AIDS-related causes in 2009 in India.[2] The clinical course of HIV disease and pattern of opportunistic infections (OIs) varies from patient to patient and from country to country. Tuberculosis is the most common OI in Indian patients with HIV. The occurrence of various AIDS-associated illnesses determines disease progression.[3] Tuberculosis is the most common OI and the most common cause of death in HIV/AIDS patients in India.[4]

HIV-1 is a neurotropic virus, central nervous system is among the most frequent and serious target of HIV infection in patients with profound immunosuppression.[5] Cryptococcus neoformans being an important cause among etiologies causing fungal meningitis.[6] With the availability of antiretroviral therapy (ART) at lower cost, the clinical profile of HIV disease in India is now changing to include drug-related toxicities and immune reconstitution syndrome. The clinical presentation and their system-wise profile is not adequately studied as changing the pattern of HIV-positive patients over a period of time.

MATERIALS AND METHODS

This was retrospective observational study carried out over a period of 1 year (January 2011–December 2011). The study was carried out at tertiary, referral care center in western Maharashtra India. All HIV patients diagnosed by NACO guidelines were enrolled (indoor patient) for detailed analysis from record section. Demographic data, clinical features, investigations, and outcome were recorded in a predesigned proforma from the case paper available at record section. Statistical analysis was performed by SSPE statistical software trial version 11. All numerical variables were entered in statistical data entry sheet and calculated for mean, standard deviation, and Chi-square test. The P < 0.05 was considered as statistically significant.

Aims and objectives

The aim of this study was to study the clinical profile and outcome of HIV/AIDS patients, which includes demographic and clinical profile of HIV patients and prevalence of different types of OI and nonopportunistic diseases at a tertiary care teaching hospital.

RESULTS

A total 111 patients were included in this observational retrospective study. Total 75 (67.56%) were male and 36 (32.43%) were female patients, predominated by male population (P < 0.05). A total 52 (46.84%) patients were presented with respiratory manifestations. Twenty-three 44.23% had pulmonary tuberculosis (TB). Seventeen patients 32.69% had community-acquired pneumonia. Six patients 11.53% had tubercular effusion. Three patients 5.76% had pleural effusion. Total 3 patients, 5.76% had Pneumocystis jirovecii pneumonia Table 1 and Figure 1. Overall respiratory manifestations were the common presentation in a present cohort of HIV seropositive patients (relative risk [RR]: 0.881; odds ratio [OR]: 0.776). Of total 111 patients, 27 (24.32%) patients were presented with neurological manifestation. Eight patients 29.62% had cerebrovascular accident. Five patients 18.51% had cryptococcal meningitis. Four patients 14.81% had tubercular meningitis. Four patients 14.81% had aseptic meningitis. Three patients 11.11% had peripheral neuropathy. One patient 3.70% had pyogenic meningitis. One patient 3.70% had neurocysticercosis. One patient 3.70% had progressive multifocal leucoencephalopathy (PMLE). The patients with CVA were outnumbered compared to all other neurological manifestation in seropositive HIV patients (RR: 0.421; OR: 0.177) Table 2 and Figure 2. A total of 31 (27.92%) patients were presented with gastrointestinal manifestations. Twelve (38.70%) had acute gastroenteritis. Six patients 19.35% had oral candidiasis. Six patients 19.35% had lymphadenitis. Three patients 9.67% had liver cirrhosis. Three patients 9.67% had hepatitis. One patient 3.22% had ileo-cecal TB Table 3. A total 17 (15.31%) patients were presented with cardiovascular manifestations. Six 35.29% had ischemic heart disease. Five patients 29.41% had myocardial infarction. Three patients 17.64% had hypertension. Three patients 17.64% had left ventricular failure Table 4. A total 32 (28.82%) patients were presented with miscellaneous manifestations. Eight patients 25% had general tonic clonic seizure. Seven patients 21.87% had pyrexia of unknown origin. Six patients 18.75% had septicemia. Six patients 18.75% had acute renal failure. Five patients 15.63% had urinary tract infection Table 5. Of total 111 patients, 17 (15.31%) patients were presented with hematological manifestation. Sixteen patients 94.11% had anemia. One patient 5.88% had non-Hodgkin's lymphoma (NHL) Table 6. Mean and standard deviation of various presentations of seropositive patients is shown in Table 7. A total of 11 (9.90%) patients succumbed and 100 patients were discharged. There was no statistically significant difference in age between succumbed and discharged patients Table 8. Respiratory manifestations including pulmonary TB were the most common presentation of patients with HIV positive status compared to the other manifestations (P < 0.001). Clinical presentation and outcome of patients with human immunodeficiency virus is shown in graph 1. Out of total 111 patients 27 (24.32%) patients were presented with the neurological manifestation of which 8 (29.62%) patients had cerebro-vascular accident. The present study reveal cerebro-vascular accident was most common neurological manifestation with P < 0.05.

Table 1

Respiratory manifestations of HIV patients

Figure 1

(a). Bilateral apical and mid zone fibro-cavitory lesions of pulmonary tuberculosis in human immunodeficiency virus (b). Right apical zone fibro-cavitory lesions with infiltrate of pulmonary tuberculosis (c). Left sided pleural effusion (tubercular) (d). Left sided hydropneumothorax (e). Left sided hydropneumothorax with ICD tube in situ (f). Bilateral extensive pneumonia in due to PCP ()

Table 2

Neurological manifestations of HIV patients

Figure 2

(a). Magnetic resonance imaging brain shows diffuse periventricular and subcortical white matter changes of progressive multifocal leukoencephalopathy inhuman immunodeficiency virus patient (b). Computed tomography brain shows left middle cerebral artery territory infarct (c). Computed tomography brain right middle cerebral artery + posterior cerebral artery territory and left cerebellar (posterior inferior cerebellar artery) infarct (d). High parietal granuloma postcontrast ring enhancing lesion (e). Computed tomography brain right fronto-parietal hemorrhage with midline shift (f). Computed tomography brain posttuberculous meningitis squeal communicating hydrocephalus

Table 3

Gastrointestinal manifestations of HIV patients

Table 4

Cardiovascular manifestations of HIV patients

Table 5

Miscellaneous manifestations of HIV patients

Table 6

Haematological manifestations of HIV patients

Table 7

Mean±SD of age of isolated clinical manifestations in HIV patients

Table 8

Mean age±SD of male and female patients with HIV (discharged and death)

Graph 1

Clinical presentation and outcome of patients with human immunodeficiency virus

DISCUSSION

The present study highlighted the clinical profile and outcome of HIV patients pertaining to opportunistic and nonopportunistic diseases. We compared our results with various studies from the different part of the country. Wadhwa et al. reported cryptococcal meningitis was seen in 5 (29.4%) patients, tubercular meningitis in 9 (52.9%) patients, HIV encephalopathy in 2 (11.7%).[6] Similarly, in our study, 27 (24.32%) patients were presented with neurological manifestation of them 5 (18.51%) had cryptococcal meningitis 4 (14.81%) had tubercular meningitis, 4 (14.81%) had aseptic meningitis, 1 (3.70%) had pyogenic meningitis. Millogo et al. Seizures are common in advanced stages of HIV infection; all cases of cryptococcal meningitis had seizures and 7% in tuberculous meningitis. In our study, 8 (25%) patients had a general tonic-clonic seizure.[7] Kaur et al. studied first 19 Indian patients with AIDS, in which diarrhea was the common presentation and TB was seen in 13 patients and the most common secondary infectious with oropharyngeal candidiasis was found in 11 patients and one patient had cryptococcosis.[8] Total 11 have died accounting for more than 50% case fatality rate. Similarly, in our study, 23 (44.23%) had pulmonary TB, 6 (11.53%) had tubercular effusion, 1 (3.22%) had ileo-cecal TB and 6 (19.35%) had oral candidiasis and 5 (18.51%) had cryptococcal meningitis with overall case fatality rate of 9.90%. The differences in the mortality could be due to early diagnosis and availability of ART now-a-days. Similarly, Misra et al. reported that the TB (pulmonary and extrapulmonary) is the major OI affecting 62% of the cases followed by candidiasis seen in 57% of the patients.[1] Singh et al. studied 100 AIDS patients with oral candidiasis (59.00%) was found to be the most common OI, followed by TB (56.00%) and P. jirovecii (7.00%).[9] In our study, 44.23% patients had pulmonary TB, 5.76% had P. jirovecii pneumonia and 19.35% had oral candidiasis. In contrast to our study, Chakraborty et al. reported oral candidiasis in 88% was found to be the most common OI, followed by TB in 57%.[10] Chakravarty et al. studied, 438 HIV positive patients attending the HIV clinic of these 354 were males and 84 were females. The mean age of the study subjects at the time of diagnosis was 32.6 years. The most common OI was TB (38.8%) followed by oropharyngeal candidiasis (20.3%) and diarrhea (12.7%). These findings are similar to our results.[11] Sharma et al. studied 135 consecutive, HIV-infected patients (age 34 ± 10 years) predominated by male patients Tuberculosis was the most common OI (71%) followed by candidiasis (39.3%), Pneumocystis jirovecii pneumonia (7.4%), cryptococcal meningitis (3.7%). Twenty-one patients (16%) died during hospital stay. Majority of deaths were due to TB and PCP.[12] Similarly in our study 23 (44.23%) had pulmonary TB, 6 (11.53%) had tubercular effusion, 6 (19.35%) had oral candidiasis, and 5 (18.51%) had cryptococcal meningitis with overall case fatality rate of 9.90%. Similar to our results, Ghate et al. reported that TB was the most common OI with an incidence of 15.4, oral candidiasis 11.3 and cryptococcal meningitis 1.7 per 100 person-years. The high incidence of commonly reported OIs in Indian HIV-infected individuals.[13] Chacko et al. studied 61 patients with AIDS and found that, 31% had chronic diarrhea, Tuberculosis in 52% patients was the most common secondary infection, 45 (74%) patients had OIs such as oropharyngeal candidiasis 25 (41%) cryptococcal meningitis 4 (7%), One (1.6%) patient or immunoblastic lymphoma 33 (54%) patients have died.[14] Similarly, in our study 38.70% had acute gastroenteritis, 44.23% had pulmonary TB, 11.53% had tubercular effusion, 19.35% had oral candidiasis, and 18.51% had cryptococcal meningitis and 1 (5.88%) had NHL with overall case fatality rate of 9.90%. Jha et al. studied 154 HIV-seropositive subjects with intestinal infections are a significant cause of morbidity and mortality in people living with HIV. The study showed a male preponderance (112 males and 42 females).[15] Similarly, in our study, 75 (67.56%) were male and 36 (32.43%) were female patients with HIV, predominated by male population with male to female ratio of 2.08:1. Similar to our findings, Madkar et al. in their 178 HIV positive patients observed that most common OPI was TB (59% of patients) followed by oral candidiasis (37.6% of patients) with male to female ratio is 3.3:1.[16] Joge et al. reported male patients (68.04%) outnumbered. A maximum number of males (79.81%) as well as females (84.77%) was in the age group of 20–39 years.[17] Deshpande et al. reported the male patients (53.4%) outnumbered. Tuberculosis (62%) was the most common OI.[18] Suthar et al. in their retrospective study of 60 HIV patients with pulmonary TB with 35 cases (58.33%) Most common OI was oral/esophageal candidiasis (22%). Total 35% of patients had typical pattern and 65% had atypical pattern of pulmonary TB on chest radiograph.[4] Wani et al. studied 128 HIV patients including 87.5% male and 12.5% females. The mean age of these patients were 34.45 ± 8.40 with male to female ratio of 7:1 with TB and candidiasis were common OI.[19] In our study the mean age was 40.8 ± 10.47 years with two-third of male population with HIV. Similar to our study, Mir et al. in their studied 26 HIV patients with mean age of presentation was 40.04 ± 7 years with male: female ratio of 4.2:1. The pulmonary TB and oropharnygeal candidiasis most common OIs.[20] Kumarasamy et al. in their retrospective study of 100 AIDS patients of them 68% were male. The most common mode of presentation was TB (61%), both pulmonary (46%) and extrapulmonary (15%). Oral candidiasis was the second most predominant OI. Similarly, in our study, 67.56% were male and 32.43% were female patients (P < 0.05) with 44.23% had pulmonary TB, 11.53% had tubercular effusion, 22% had ileo-cecal TB and 19.35% had oral candidiasis.[21] Overall OPs, non-OPs, male predominance and mean age of HIV in the present study are comparable with other study. The mortality was significantly low in our study. The present report highlights the clinical manifestations related to HIV infection from the Maharashtra of India.

CONCLUSIONS

Overall respiratory manifestations were the common presentation in present cohort of HIV seropositive patients and TB was the most common OI. The present study reveal cerebrovascular accident was most common neurological manifestation. Two-third of HIV patients were male. About half of the patient had OIs. Tuberculosis, candidiasis, cryptoccocal meningitis and P. jirovecii pneumonia were the most common OIs in the present study. Overall case fatality rate was 9.90%. The mortality was more often seen with respiratory and neurological manifestations. Anemia, diarrhea, oropharyngeal candidiasis, ischemic heart disease were the most common hematological, gastrointestinal, and cardiovascular manifestation respectively in HIV patients. Clinicians should consider HIV in the differential diagnosis and management of all persons with TB. Emphasis needs to be given to the early diagnosis and management of TB in HIV-infected individuals. A wide spectrum of disease, including both OIs and noninfectious opportunistic diseases, is seen in hospitalized HIV-infected patients from Western Maharashtra. Tuberculosis remains the most common OI and is the commonest cause of death in these patients. Cryptococcal meningitis indicates progression of HIV infection toward AIDS and is useful as a reference to starting ART in settings where facilities for determination of CD4 counts are not available. The study emphasizes that, education; counseling, early diagnosis of OIs, awareness of the disease and early anti-viral drug treatment can help to bring down the number of AIDS cases. There is need for early screening and increasing awareness in healthcare providers to make a diagnosis of HIV so as to reduce morbidity and mortality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest