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Part 5 Stages of AIDS clinical manifestations

HIV infection cause progressive injury to the immune system of human body, leading to extreme lowering of immune system, AIDS and death of complicating diseases. From HIV infection to AIDS, it can be divided into 4 stages: acute infection stage, asymptomatic stage, AIDS relevant syndrome stage and AIDS stage. In 1993, the classification and diagnosis standard were also put forward.
1.Clinical stages of HIV infection.
1.1Acute infection stage
Acute infection stage usually starts from 2-6 weeks after HIV infection. In this period, influenza-like symptoms are present for some patients. This a rapid reaction of immune system to the quick and broad spread of HIV in the body, mainly manifested as viremia, and in the blood, HIV antigens instead of antibodies can be detected. The clinical manifestations are fever, angina, skin rash, generalized muscle and joint pains and generalized lymphadenectasis, analogous to influenza viral infection, and for some patients, fever, headache, emesis and meningeal irritation, analogous to acute meningitis. In the Northern Hemisphere, 30% patients have clinical manifestations of acute infection after HIV infection for the first time. The manifestations usually last 1-3 weeks and then disappear of themselves. But in Africa, very few patients complain of the symptoms of acute infection, even if these symptoms appear, they are often diagnosed as malaria, because malaria is a disease that almost every African has or often has infected. Therefore, most AIDS patients in Africa can not recall when they have manifestations of acute infection.
1.2Asymptomatic stage
Asymptomatic stage is also called incubation period and may last several months to several years. The duration of incubation period is related to the quantity of infectious viruses, the intensity of virus strain toxicity, the type of virus, the individual difference of immune system and the nourishment state of patients. For example, the infectivity of those who have taken blood and blood products containing large quantity of HIV is stronger than those who have been infected through sexual contact. In addition, the intensity of virus toxicity has also something to do with the speed of virus replication.?
Some scholars have separated viruses from and cultured them out of the patients who have short incubation period and quick progress of illness and the patients who have longer incubation period and no clinical manifestations and found that in the former, the viruses reproduce themselves faster and the toxicity stronger than the later, and this type of viruses are mostly seen in HIV-1 infected patients, while those with serum antibody positive and without clinical symptoms for a long time are mostly HIV-2 infected. The diagnosis of HIV infection in asymptomatic period is mainly based on serum antibody test instead of antigen test. Through antibody test, it can be found the in the former cases, accessory T lymphocytes are progressively decreasing and immune function gradually damaged until significant lowering of immune function and the appearance of clinical symptoms. Among HIV-1 infected, about 30% get ill 2-5 years after infected, about 50% develop into AIDS within 10 years and a few are at incubation stage and dont get ill. But these few people are also dangerous infection sources. They have no self-feeling symptoms and perhaps dont know they are infected with HIV, but they can transmit HIV to others through blood and sexual contact. Mothers at incubation period may transmit HIV to their babies.
1.3AIDS relevant syndrome stage
Along with the progressive invasion of HIV to human bodys immune system, mainly to T4 cells, The T4 cell count will be less than 400/mm3 and T4/T8 less than 1. Partial damage of immune function may lead to various kinds of infectious diseases with symptoms like tuberculosis such as low fever, night sweat, malaise and emaciate and often accompanied with shallow lymph node enlargement, throat lymph tissue hyperplasia and tonsil enlargement as well as increase of macrophages and lymphocytes for some patients. Lymph node enlargement occurs for the most part in neck, armpit, groin and behind ears, and the enlarged lymph nodes, with a diameter of 1-2cm, are smooth, motive, without tenderness and subsidence for several months. On histologic test with biopsy, lymph filtrated bubble hyperplasia can be seen. Opportunistic infection may appear for some patients, such as thrush, Herpes simplex virus infection, genital condyloma acuminate, infectious molluscum, large and multiple molluscum on the head and face, multiple itching skin rash and steatorrhea skin rash with red scale-shape papules that often occur on the head and face and sometimes on the general skin. This situation may become serious. Lab examination may show the decrease of haemoglobins and platelets, significant increase of IgG and HIV antibody positive apart from the decrease of T4 cells. AIDS relevant syndrome stage can last several years, but for some patients, fateful opportunistic infection may occur suddenly and develop into AIDS.
1.4AIDS stage
AIDS stage is the period when acquired immunodeficiency syndrome occurs. In this period, multiple systematic injuries with opportunistic infection and malignant pathological changes happen because of extreme lowering of immune system functions of the organism.

  • Opportunistic infection
  • Opportunistic infection refer to conditional causative agent infection, namely, some conditional causative agents exist normal and health human body and dont cause disease, but at the late stage of HIV infection, the serious injury of immune system provides an opportunity to conditional causative agents to infect every parts of the body. These causative agents include protozoons, bacteria, fungi and viruses. Common causative agents are listed in Table 5-1.

    Table 5-1 Common causative agents in opportunistic infection

    Protozoon infection


    Pneumocystis carinii


    Rat toxoplasm


    Giardia lamblia


    Entamoeba histolytica and Giardia lamblia


    Isosporiasis belli

    Bacterium infection


    Tubercle mycobacterium


    Mycobacterium avium


    Rat typhoid mycobacterium




    Mononuclear cell increase listeria monocytogenes

    Fungus infection


    Candida albicans


    New type Xianqiu virus




    Coccidioide immitis



    Viral inections




    Herpes simplex virus


    Herpes zoster virus




    Lymphoma virus


    EB virus

  • Malignant pathological changes
    (1)Kaposis sarcoma
    Kaposis sarcoma is the most common malignant tumor suffered by male homosexual population and characterized by multiple blood vessel nodes on skin. At the early stage of illness, the tumors often occur in lower limbs taking the shape of sheet maculopapules in amaranth and indigo colors, and develop into tuberculous plaques. The tumors can infiltrate into the subcutaneous tissue and skeleton and skin ulcer may occur on the surface of tumors. The pathological changes can diffuse and spread to head, trunk and external genitalia, and also to internal organs such as liver, spleen and gastrointestinal tract.
    (2)Non-Hodgkins lymphomas
    95% of non-Hodgkins lymphomas occur in the peripheral tissue of lymph, mainly involving bone marrow, liver, central nervous system and alimentary canal. Those originated from the bone marrow may have the trend of fever, anaemia and bleeding, with abnormal blood picture and bone marrow; those in the liver are representative of hepatomegaly and abdominal distention, and the appearance of jaundice and dyscrasia at the late stage; and for those originated from nerve, a series of symptoms of intracranial space-occupying lesion may occur and progressive deterioration happens. Test with CT and magnetic resonance display shows pathological changes surrounding the ventricle, and pathologic test shows giant tumor cells that have penetrated into the intervals about blood vessels and cerebral pia mater. Serum giant cell viral antibodies are positive in reaction, suggesting the onset of the disease is related to the complication of cytomegalovirus infection. The clinical manifestations of lymphoma in gastrointestinal tract are abdominal distention, bellyache, abdominal mass, abnormal defecation and alimentary canal bleeding.
    (3)Other malignant tumors Other malignant tumors may also occur in patients with AIDS and take corresponding clinical manifestations, developing fast and spreading far.
  • 1.4.3 Other complications:
  • Significant emaciate and severe malnutrition, anaemia and decrease of leucocytes, platelets whole blood cells are present in patients with AIDS. In addition, long term diarrhea may cause the disturbance of water and electrolyte; the injury of nervous system may cause intelligence lowering, irresponsibility, depression, anxiety, paranoia-like paranoia psychosis and dementia; the injury of blood vessel system may cause tachycardia, cardiac enlargement and congestive cardiac failure; the injury of kidney function may cause interstitial nephritis and renal tubule putrescence, present with albuminuria, uropenia, oedema, azotaemia and kidney function failure; the injury of muscle and bone marrow system may cause wandering arthritis, arthralgia, joint thydrops and rheumatoid arthritis, as well as polymyositis, muscle tenderness and movement disturbance representative of necrotic myositis in biopsy; and the injury of endocrine system may cause adrenal gland hypofunction, diabetes and adrenal crisis.
    (1)Pneumocystis carinii pneumonis ( PCP)
    Pneumocystis carinii pneumonis is also called pneumocystosis or mesenchyme plasma cell pneumonia. Its causative agent was first found in 1909, at that time, it was thought to be a type of polymastigotes. During the World War II, it caused pneumonia among children who were in serious malnutrition. Now it seems that the pneumocystis carinii has a closer relationship with fungus than with shiogusa. This type of protozoon organism is part of normal biota that exists in normal people, and causes illness only on the occasion of extreme low of immune functions. The first case of PCP was found in USA in 1954, and prior to the spread of AIDS, PCP was discovered only in the patients whose immune function was restrained by the main or secondary cause of disease, or the patients who had congenital immunodeficiency or had been treated with chemotherapy because of cancer, or the patients who had taken immunosuppressor following transplant operation. Medical staff and other patients have no danger to be infected by PCP in case of immunity not suppressed.
    The acute attack of PCP with clinical manifestations of fever, intolerance of cold, chough, oppressed feeling in chest and chest pain may last several weeks or several months, and in hospitals, patients with shortness of breath, blue jaundice of lips and unable to breath deeply are often seen. A few cases are of short medical history and rapid development, starting from high fever and accompanied with short breath, oppressed feeling in chest, dyspnea and even acute respiratory failure.
    Toxoplasmosis is caused by rat toxoplasm that is very small and infests in cells, and its causative agents are found in cat and some other mammals. Human being may be infected when have contacted with the causative agents or eaten the meat of cattle, sheep of pig that have been infected. But this infection is always without symptoms and has clinical symptoms only when immune function is low. In patients with AIDS, toxoplasm may induce various clinical symptoms, the most common one being toxoplasm encephalitis.
    Patient usually presents with neural symptoms, such as headache, dizziness, twitch and hepatic coma, as well as high fever and soporous state. All the symptoms and signs simulate brain space-occupying lesion, very serious and dramatically worsening. Sometimes, toxoplasm also causes pneumonia and myocarditis.
    Examination with X-ray, Ct nuclear magnetic resonance and scan, lumbar puncture and serodiagnosis mayshow abnormal, but without specificity for the patient with toxoplasm encephalitis. However, the finally diagnosis is dependent on brain biopsy.
    (3)Ameba and Giardia lamblia intestinal disease In the first 10 years of AIDS spreading, it was found that the infection rate of parasitosis among homosexual population is very high and the disease was once named homosexual intestinal tract syndrome. The disease is one of common causes that lead to diarrhea of patient with AIDS. Ameba protozoon usually infests at the end of colon and ileum, clinically presenting with fishy and mucous bloody stool. Giardia lamblia infest at the upper end of small intestine, typically presenting with watery stool Or even bloody stool.
    (4)Tubercle mycobacterium infection
    For the patient concurrently infected with tubercle mycobacterium and HIV, the injury of immune function is much more serious, which leads to a rapid course and bad outlook. In Africa, 98% of male patients with tuberculosis are complicated by HIV infection. At present, tubercle infection is a significant clinical symptom of AIDS and also an important indication in diagnosis. AIDS complicated with tuberculosis outside of lungs is much more common, and because of immunodeficiency, it is easier for tubercle mycobacterium to spread from primarily infected lungs to peripheral viscera, and common tubercle infections are tuberculosis, pleural tuberculosis, intestinal tuberculosis, meningeal tuberculosis and bone tuberculosis. Patient with AIDS and complicated by tuberculosis has much anti-drug strains and bad treatment reaction. It has been found in recent years that tuberculosis transmits rapidly among admitted patients with AIDS, and therefore, it is important to take isolation and prevention measures in hospitals.
    (5)Candida albican disease
    Candida albicans usually infect mouth, throat, esophagus and gastrointestinal tract mucous membrane, presenting with congestion and hydrops on the surface of the tongue as well as on the mucous membrane of the mouth and throat accompanied with causalgia and salivate, and the pathological change involves the oesophagus, leading to dyscatabrosis, and also the intestinal tract, leading to diarrhea.
    Crytococcosis is caused by a new type of busse-buschke that is a fungus. The busse-buschke is a kind of accessory enzymes and can be found in the foil and faeces of pigs and birds. For some patients with low immunologic function, it mainly induces sub-acute meningitis and encephalitis, and also infections in other parts of the body (such as lungs, urinary system and genital system). Busse-buschke infection was found among patients with Hodgkins disease before the spread of AIDS, and patients with AIDS and busse-buschke encephalitis are commonly seen, manifested as headache, low fever, emesis, blurred visionblurred vision, disorder of consciousness and meningeal irritation. The diagnosis of busse-buschke encephalitis is usually conducted by the detection of busse-buschkes through cerebrospinal fluid smear and ink coloration and confirmed by the culture and finding of busse-buschke growth.