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Common opportunistic infections and tumours if HIV and low CD4 count

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

opportunistic infections and tumours

Patients with a CD4 count of <200x10^6/litre are susceptible to infections by pathogens which would not normally cause disease in an immunocompetent individual.
Common opportunistic infections are:

  • pneumocystis carinii pneumonia
  • cerebral toxoplasmosis
  • oesophageal candidiasis
  • diarrhoea, pathogens including:
    • cryptosporidium
    • CMV
    • atypical mycobacteria

Common malignant diseases includes:

  • Kaposi's sarcoma
    • the most common tumour in people with HIV infection
    • is an AIDS-defining illness and is caused by the Kaposi sarcoma herpesvirus (KSHV).
  • high-grade B cell non-Hodgkin's lymphoma
    • two commonest subtypes are diffuse large B-cell lymphoma (DLBCL) and Burkitt lymphoma/leukaemia (BL)
    • both are considered as AIDS-defining illnesses (ADI).
    • is the second most common tumour in individuals with HIV
    • studies have indicated a decline in incidence since the introduction of HAART
    • development of AIDS-related lymphomas (ARLs) has been shown to be related to older age, low CD4 cell count and no prior treatment with HAART
  • cervical carcinoma
    • almost all cases of invasive cancer are associated with infection with oncogenic types of human papilloma virus (HPV), particularly HPV 16 and 18
    • women with HIV infection are more likely to have infection with HPV 16 or 18 than women who are HIV negative
    • Invasive cancer is preceded by cervical intraepithelial neoplasia (CIN) which has a higher prevalence and incidence in women with HIV infection (1)


  • all patients with HIV and malignancy should be referred to centres that have developed expertise in the management of these diseases
  • most serious problems usually occur at very low CD4 counts (below 100 cells/μl) so other clinical clues to immunosuppression are likely to be present.
    • Pneumocystis pneumonia (PCP) is an exception to this rule as it tends to occur at higher CD4 counts (below 200).
      • it may be the first HIV-related problem for which the patient seeks advice
      • the prognosis correlates directly with how early or late the infection is identified and treated: PCP can kill if diagnosed too late (2)










clinical indicator diseases for adult HIV infection


AIDS-defining conditions

other conditions where HIV testing should be offered


  • tuberculosis
  • pneumocystis
  • bacterial pneumonia
  • aspergilosis


  • cerebral toxoplasmosis
  • primary cerebral lymphoma
  • cryptococcal meningitis
  • progressive multifactorial leucoencephalopathy
  • aseptic meningitis/encephalitis
  • cerebral abscess
  • space occupying lesions of unknown origin
  • Guillain -Barré syndrome
  • transverse myelitis
  • peripheral neuropathy
  • dementia
  • leucoencephalopathy


  • kaposi "s sarcoma
  • severe or recalcitrant seborrhoeic dermatitis
  • severe or recalcitrant psoriasis
  • multidermatomal or recurrent herpes zoster


  • persistent cryptosporidiosis
  • oral candidiasis
  • oral hairy leukoplakia
  • chronic diarrhoea of unknown cause
  • weight loss of unknown cause
  • salmonella, shigella or campylobacter
  • hepatitis B & C infection


  • non-Hodgkin "s lymphoma
  • anal cancer or anal intraepithelial dysplasia
  • lung cancer
  • seminoma
  • head and neck cancer
  • Hodgkin "s lymphoma
  • Castleman "s disease


  • cervical cancer
  • vaginal intraepithelial neoplasia
  • cervical intraepithelial neoplasia Grade 2 or above



  • any unexplained blood dyscrasia including:
    • thrombocytopenia
    • neutropenia
    • lymphopenia


  • cytomegalovirus retinitis
  • infective retinal diseases including herpesviruses and toxoplasma
  • any unexplained retinopathy



  • lymphadenopathy of unknown cause
  • chronic parotitis
  • lymphoepithelial parotid cysts



  • mononucleosis-like syndrome (primary HIV infection)
  • pyrexia of unknown origin
  • any lymphadenopathy of unknown cause
  • any sexually transmitted infection


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