HIVIN

ORTHOPAEDICS

DR MAULIK T PATEL

Department of Orthopedics,

Meenakshi mission hospital

INTRODUCTION

ACQUIRED IMMUNODEFICIENCY SYNDROME

HUMAN IMMUNODEFICIENCY VIRUS

PANDEMIC NO CURE YET

STATISTICS

Deaths Annually: 14,802 (1999) Death Rate: 5.4 deaths per 100,000 population (1999)

STATISTICS

Number of Cases: 20,550 (January-June 2000) Hospital Discharges for Patients with HIV Diagnosis: 180,000 (1999) Number of Days of Care for Patients with HIV Diagnosis: 1,310,000 (1999) Average Length of Hospital Stay: 7.3 days (1999)

INTRODUCTION DISABILITY OR LIFE THREATENING

ILLNESS CAUSED BY HIV CHARACTERISED BY HIV ENCEPHALOPATHY,HIV WASTING SYNDROME, DISEASES DUE TO IMMUNODEFICIENCY IN A PERSON WITH LAB EVIDENCE OF HIV INFECTION OR WITHOUT OTHER CAUSES OF IMMUNODEFICIENCY

DEFINITION (1993) CDC

ANY HIV INFECTED INDIVIDUAL WITH A CD4+ T CELL COUNT OF LESS THAN 200/µL HAS AIDS REGARDLESS OF THE PRESENCE OF SYMPTOMS OR OPPORTUNISTIC DISEASE

CLASSIFICATIONClinical categories

Cd4 count

A

Asymptomatic a/c hiv or pgl

B

Symptomatic not AorC

C

Aids indicator conditions

>500 A1 B1 C1

200-499 A2 B2 C2

<200 A3 B3 C3

INTRODUCTION

FIRST REPORTED IN 1981 IN USA GRID VIRUS LUC MONTAGNIER 1983 , PARIS

HUMAN IMMUNODEFICIENC

Y VIRUS REVERSE TRANSCRIPTASE ENZYME INFECTION LIFE LONG ASYMPTOMATIC FOR MANY YEARS VIRUS IS FRAGILE- DESTROYED BY BOILING

FOR ONE SECOND, 1% BLEACH ,70% ETHANOL, 2% GLUTERALDEHYDE,5% FORMALDEHYDE, 1% CHLORINE-SODIUM HYPOCHLORITE, 3% H2O2

STRUCTURE OF HIV

MODES OF TRANSMISSION

SEXUAL INTERCOURSE TRANSFUSION SYRINGES & NEEDLES PRENATAL & PERINATAL ORGAN TRANSPLANTS DIALYSIS

MODES OF TRANSMISSION

HIV IS NOT TRANSMITTED BY SOCIAL CONTACTS

LIFE CYCLE

HIV INFECTS A PERSON IN MANY WAYS AND………

AIDS VIRUS IN BLOOD STREAM

LIFE CYCLE

IMMUNE SYSTEM FIGHTS BACK IN THREE WAYS. WITH………….

ANTIBODIES

MACROPHAGES

KILLER T CELLS

LIFE CYCLE

THE DEFENCE IS COORDINATED BY…

HELPER T CELLS

LIFE CYCLE

BUT……….

HIV ATTACHES TO CD4 RECEPTOR ON T CELLS

LIFE CYCLE

INSIDE THE CELL IT IS SAFE ……

VIRAL RNA IS TRANSCRIBED INTO DNA

LIFE CYCLE

AFTER A WHILE THE VIRUS COMES OUT OF HIDING AND REPRODUCE..

THE DNA IS TRANSCRIBED INTO MANY COPIES OF RNA

RNA PRODUSE PROTIENS OF THE VIRUS

PROTIENS ARE THEN CUT INTO USABLE PIECES AND PACKAGED WITH RNA

LIFE CYCLE

THE NEW VIRUSES THUS PRODUCED …..

BUDDS OFF FROM THE T CELL

LIFE CYCLE THESE THEN GO ON TO INFECT

OTHER T CELLS THUS WEAKENING THE IMMUNE SYSTEM

THIS WILL ENABLE THE ENTRY OF OTHER PATHOGENS INTO THE BODY

PATHOGENESIS

PRIMARY HIV INFECTION,INITIAL VIREMIA & DISSEMINATION OF VIRUS

ESTABLISHMENT OF CHRONIC & PERSISTENT INFECTION

ADVANCED HIV DISEASE

COURSE OF HIV PT

PATHOGENESIS

ROLE OF LYMPHOID ORGANS ROLE OF CELLULAR ACTIVATION ROLE OF APOPTOSIS SUPER ANTIGENS AUTOIMMUNE PHENOMENA COFACTORS CYTOKINE NETWORK

IMMUNE RESPONSE

HUMERAL

antibodies to p24 p17 & p55

antibodies to gp160 gp 120 gp88

gp41 CELLULAR

ANTIBODY RESPONSE

ANTIGENEMIA & ANTIBODY

DIAGNOSIS

SCREENING TEST – ELISA

CONFIRMATORY - WESTERN - BLOT DIRECT HIV DETECTION

P24 AG CAPTURE ASSAY

HIV RNA BY PCR

WESTERN BLOT

CLINICAL MANIFESTATIONS

THE ACUTE HIV SYNDROME ASYMPTOMATIC STAGE EARLY SYMPTOMATIC NEUROLOGIC DISEASE OPPORTUNISTIC INFECTIONS NEOPLASTIC DISEASE

MANAGEMENT

PREVENTION IS BETTER THAN CURE

MANAGEMENT

HEALTH CARE WORKER

RISK OF INFECTION WITH A HOLLOW BORE NEEDLE PRICK – 0.3%

RISK WITH SUTURE NEEDLE IS LESS

PREVENTION

REGULAR HAND WASHING COVER WOUNDS/SKIN LESIONS PROTECT EYES , MOUTH & NOSE NEVER TRANSFER SHARP OBJECTS

DIRECTLY NEVER RECAP A NEEDLE , PROPER

DISPOSAL OF SHARP OBJECTS CONSIDER EVERY PT AS A POTENTIAL

RISK – STICK TO UNIVERSAL PRECAUTIONS

PREVENTION

DOUBLE GLOVES PLASTIC APRON WATER RESISTANT SHOE COVER FACE SHIELD OR GOGGLES

EXPOSURE

SPLASH ON THE SKIN WASH THOROUGHLY WITH SOAP

& WATER DIP HANDS IN UNDILUTED

SAVLON FOR 15 SEC.

EXPOSURE NEEDLE STICK INJURY LET THE WOUND BLEED FREELY WITHOUT PRESSING IT THOROUGHLY WASH DIP HANDS IN UNDILUTED SAVLON FOR 15 SEC. TEST THE PT FOR HIV TEST SELF AT 3 , 12 , & 24 WEEKS

EXPOSURE

IF PT IS NEGATIVE FOLLOW UP AT 3 , 12 , 24 WEEKS

TAKE THE HISTORY OF THE PT- HIGH RISK BEHAVIOR

USE CONDOMS WITH THE PARTNER FOR 6 MONTHS

POST EXPOSURE DRUG

PROPHYLAXIS AZIDOTHYMIDINE

WITHIN ONE HOUR OF EXPOSURE 200mg q4h FOR 72 HRS 100 – 200mg Q4H FOR 25 DAYS

STRATEGIES HELP THE IMMUNE SYSTEM

VACCINE

VACCINE INDUCED ANTIBODIES

STRATEGIES

Problems with this approach. Scientists have to make sure the vaccine itself

doesn't make people ill. HIV is constantly changing, so the defenses

stimulated by a vaccine might not be effective in fighting the actual virus.

And if even a single virus escapes by hiding out inside a cell, it could go on to make thousands of copies of itself.

STRATEGIES

ARTIFICIAL DECOY CD4 UNITS CAN BE GIVEN

HIV WILL ATTACH TO THESE INSTEAD OF T CELLS

DECOY CD4

STRATEGIES

USE OF DRUGS THAT LOOK LIKE BUILDING BLOCKS OF DNA

PREVENT CONVERTION OF VIRAL RNA INTO DNA

DRUGS

HIV is constantly changing, and eventually it is no longer tricked by these faulty building blocks. HIV becomes resistant to these drugs, and the life cycle continues the same as before. Another problem is that these drugs can damage non-infected cells which also need to make DNA to reproduce.

STRATEGIES

STOPPING THE PRODUCTION OF VIRAL PROTEINS WITH DRUGS

PREVENTION OF SPLICING

PREVENTION OF REPLICATION

STRATEGIES

BOOST THE IMMUNE SYSTEM OF THE PT

TREAT OPPORTUNISTIC INFECTIONS

ORTHOPAEDIC PROBLEMS

RHEUMATOID ARTHRITIS ARTHRALGIAS REACTIVE ARTHRITIS AIDS ASSOCIATED ARTHROPATHY FIBROMYALGIA SEPTIC ARTHRITIS

ORTHOPAEDIC PROBLEMS

RHEUMATOID ARTHRITIS-AMELIORATED IN SPITE OF HIGH LEVELS OF ANTI PHOSPHOLIPID ABS&ANTINUCLEAR ABS.

REACTIVE ARTHRITIS

33% AIDS PTS HAVE ARTHRALGIAS

5-10% REITER’S / PSORIATIC

AIDS ASSOCIATED ARTHROPATHY

JOINT PROBLEMS WITH NO CAUSE SUBACUTE OLIGOARTHRITIS 1 – 6 WEEKS LASTS 6 WKS – 6 MONTHS LARGE JTS-KNEE / ANKLE

AIDS ASSOCIATED ARTHROPATHY

NONEROSIVE X-RAY NONREVEALING RESPOND TO INTRA ARTICULAR

STEROID

AIDS ASSOCIATED ARTHROPATHY

PAINFUL ARTICULAR SYNDROME-

10% PTS

A/C SEVERE,SHARP PAIN

KNEE,ELBOW,SHOULDER

LASTS 2 – 24 HRS

NARCOTIC ANALGESICS

FIBROMYALGIA

WIDESPREAD MUSCULOSKELETAL PAIN OF 3 MONTHS

11 OF 18 TENDER POINTS

SEPTIC ARTHRITIS

RARE FUNGAL-

CRYPTOCOCCUS,SPOROTHRIX MYCOBACTERIAL-M.HEMOPHILUM COMMON IN HAEMOPHILIACS

ORTHOPAEDIC PROBLEMS

SURGERY MAY PROMOTE CLINICAL AIDS IN SEROPOSITIVE PTS

AIDS & ORTHOPAEDIC

SURGEON

IGNORANCE BREEDS FEAR

FRACTURES

CLOSED # HEAL NORMALLY WITH CONSERVATIVE TREATMENT

HIGH INFECTION RATE WITH ORIF OPEN # -- INFECTION & NONUNION

COLD SURGERY

INCREASED RISK OF SEPSIS RELATED TO STAGE OF AIDS

TUBERCULOSIS

DUAL EPIDEMIC HIV & TB ARE SYNERGISTIC WASTING DISEASE , NIGHT SWEATS REST , FOOD , DRUGS PROGNOSIS POOR

OTHER INFECTIONS

TROPICAL PYOMYOSITIS HEMATOGENOUS OSTEOMYELITIS LATE INFECTION OF IMPLANTS

RISK OF TRANSMISSION OF HIV FROM PT TO SURGEON IS SMALL

FROM SURGEON TO PT IS EVEN LESS

RISK ACCUMULATE OVER TIME

PUT LARGER INCISION OPERATE BY SIGHT THAN

FEEL NO SHARP INSTRUMENT

SHOULD BE HANDED DIRECTLY

“WE MUST HAVE OPERATED ON MANY HIV POSITIVE PTS BEFORE THE DANGERS WERE RECOGNISED OR PRECAUTIONS PUT IN PLACE, BUT SENIOR SURGEONS HAVE NOT BEEN DYING OF HIV INFECTIONS.”

- J.E.JELLIS

Increased Abdominal Visceral Fat Is Associated With Reduced Bone Density in HIV-Infected Men With Lipodystrophy

disrupted fat metabolism may account for HIV-related osteopenia.

abnormal marrow or whole body fat metabolism may affect bone cell differentiation or the marrow cytokine environment in people with HIV-related lipodystrophy."

ANTIRETROVIRAL THERAPY

NUCLEOSIDE ANALOGUES ZIDOVUDINE DIDANOSINE ZALCITABINE STAVUDINE LAMIVUDINE

ANTIRETROVIRAL THERAPY

NONNUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS

NEVIRAPINE DELAVIRDINE

ANTIRETROVIRAL THERAPY

PROTEASE INHIBITORS SAQUINAVIR RITONAVIR INDINAVIR NELFINAVIR

ANTIRETROVIRAL THERAPY

TRIPPLE THERAPY TWO NUCLEOSIDES & ONE

PROTEASE INHIBITOR