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commonly than among immunocompetent persons Although a purified protein derivative (PPD) test should be performed on all HIV-infected persons in whom a diagnosis of tuberculosis is being considered, the lower the CD4 cell count, the greater the likelihood of anergy Because anergy skin test panels do not accurately classify those patients who are infected with tuberculosis but unreactive to the PPD, they are not recommended Treatment of HIV-infected persons with active tuberculosis is similar to treatment of HIV-uninfected tubercular individuals (see Figure 31 1) However, rifampin should not be given to patients receiving indinavir, nelfinavir, amprenavir, lopinavir, or delavirdine In these cases, rifabutin may be substituted, but it may require dosing modifications depending on the antiretroviral regimen Multidrug-resistant tuberculosis is a major problem in several metropolitan areas Noncompliance with prescribed antituberculous drugs is a major risk factor Several of the reported outbreaks appear to implicate nosocomial spread The emergence of drug resistance makes it essential that antibiotic sensitivities be performed on all positive cultures Drug therapy should be individualized Patients with multidrug-resistant M tuberculosis infection should receive at least three drugs to which their organism is sensitive Atypical mycobacteria can cause pulmonary disease in AIDS patients with or without preexisting lung disease and responds variably to treatment Making a distinction between M tuberculosis and atypical mycobacteria requires culture of sputum specimens If culture of the sputum produces acid-fast bacilli, definitive identification may take several weeks using traditional techniques DNA probes allow for presumptive identification usually within days of a positive culture While awaiting definitive diagnosis, clinicians should err on the side of treating patients as if they have M tuberculosis infection In cases in which the risk of atypical mycobacteria is very high (eg, a person without risk for tuberculosis exposure with a CD4 count under 50 cells/mcL see Figure 31 1), clinicians may wait for definitive diagnosis if the person is smear-negative for acid-fast bacilli, clinically stable, and not living in a communal setting Isolation of cytomegalovirus (CMV) from bronchoalveolar lavage fluid occurs commonly in AIDS patients but does not establish a definitive diagnosis Diagnosis of CMV pneumonia requires biopsy; response to treatment is poor Histoplasmosis, coccidioidomycosis, and cryptococcal disease should also be considered in the differential diagnosis of unexplained pulmonary infiltrates c Noninfectious pulmonary diseases Noninfectious causes of lung disease include Kaposi s sarcoma, nonHodgkin s lymphoma, and interstitial pneumonitis In patients with known Kaposi s sarcoma, pulmonary involvement complicates the course in approximately one-third of cases However, pulmonary involvement is rarely the presenting manifestation of Kaposi s sarcoma Non-Hodgkin s lymphoma may involve the lung as the sole site of disease but more commonly involves other organs as well, especially the brain, liver, and gastrointestinal tract Both of these processes may show nodular or diffuse parenchymal involvement, pleural effusions, and mediastinal adenopathy on chest radiographs Nonspecific interstitial pneumonitis may mimic Pneumocystis pneumonia Lymphocytic interstitial pneumonitis seen in lung biopsies has a variable clinical course Typically, these.

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niques cannot distinguish these two diseases with certainty, lymphoma more often is solitary Other less common lesions should be suspected if there is preceding bacteremia, positive tuberculin test, fungemia, or injection drug use These include bacterial abscesses, cryptococcomas, tuberculomas, and Nocardia lesions Because techniques for stereotactic brain biopsy have improved, this procedure plays an increasing role in diagnosing cerebral lesions Biopsy should be strongly considered if lesions are solitary or do not respond to toxoplasmosis treatment, especially if they are easily accessible Diagnosis of lymphoma is important because many patients benefit from treatment (radiation therapy) In the future, it may be possible to avoid brain biopsy by utilizing polymerase chain reaction (PCR) assay of cerebrospinal fluid for Epstein Barr virus DNA, which is present in 90% of CNS lymphoma cases c AIDS dementia complex The diagnosis of AIDS dementia complex (HIV-associated cognitive-motor complex) is one of exclusion based on a brain imaging study and on spinal fluid analysis that excludes other pathogens Neuropsychiatric testing is helpful in distinguishing patients with dementia from those with depression Patients with AIDS dementia complex typically have difficulty with cognitive tasks and exhibit diminished motor speed Patients may first notice a deterioration in their handwriting The manifestations of dementia may wax and wane, with persons exhibiting periods of lucidity and confusion over the course of a day Many patients improve with effective antiretroviral treatment Metabolic abnormalities may also cause changes in mental status: hypoglycemia, hyponatremia, hypoxia, and drug overdose are important considerations in this population Other less common infectious causes of encephalopathy include progressive multifocal leukoencephalopathy (discussed below), CMV, syphilis, and herpes simplex encephalitis d Cryptococcal meningitis Cryptococcal meningitis typically presents with fever and headache Less than 20% of patients have meningismus Diagnosis is based on a positive latex agglutination test that detects cryptococcal antigen (or CRAG ) or positive culture of spinal fluid for Cryptococcus Seventy to 90% of patients with cryptococcal meningitis have a positive serum CRAG Thus, a negative serum CRAG test makes a diagnosis of cryptococcal meningitis unlikely and can be useful in the initial evaluation of a patient with headache, fever, and normal mental status HIV meningitis, characterized by lymphocytic pleocytosis of the spinal fluid with negative culture, is common early in HIV infection e HIV myelopathy Spinal cord function may also be impaired in HIV-infected individuals HIV myelopathy presents with leg weakness and incontinence Spastic paraparesis and sensory ataxia are seen on neurologic examination Myelopathy is usually a late manifestation of HIV disease, and most patients will have concomitant HIV encephalopathy Pathologic evaluation of the spinal cord reveals vacuolation of white matter Because HIV myelopathy is a diagnosis of exclusion, symptoms suggestive of myelopathy should be evaluated by lumbar puncture to rule out CMV polyradiculopathy (described below) and an MRI or CT scan to exclude epidural lymphoma.

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