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identified cause of diarrhea are considered to have a presumptive diagnosis of AIDS enteropathy Patients may respond to institution of effective antiretroviral treatment Upper endoscopy with small bowel biopsy is not recommended as a routine part of the evaluation e Other disorders Two other important gastrointestinal abnormalities in HIV-infected patients are gastropathy and malabsorption It has been documented that some HIVinfected patients do not produce normal levels of stomach acid and therefore are unable to absorb drugs that require an acid medium This decreased acid production may explain, in part, the susceptibility of HIV-infected patients to Campylobacter, Salmonella, and Shigella, all of which are sensitive to acid concentration There is no evidence that Helicobacter pylori is more common in HIV-infected persons A malabsorption syndrome occurs commonly in HIVinfected patients It can be due to infection of the small bowel with M avium complex, Cryptosporidium, or microsporidia 10 Endocrinologic manifestations Hypogonadism is probably the most common endocrinologic abnormality in HIV-infected men The adrenal gland is also a commonly afflicted endocrine gland in patients with AIDS Abnormalities demonstrated on autopsy include infection (especially with CMV and M avium complex), infiltration with Kaposi s sarcoma, and injury from hemorrhage and presumed autoimmunity The prevalence of clinically significant adrenal insufficiency is low Patients with suggestive symptoms should undergo a cosyntropin stimulation test Although frank deficiency of cortisol is rare, an isolated defect in mineralocorticoid metabolism may lead to saltwasting and hyperkalemia Such patients should be treated with fludrocortisone (01 02 mg daily) AIDS patients appear to have abnormalities of thyroid function tests different from those of patients with other chronic diseases AIDS patients have been shown to have high levels of triiodothyronine (T3), thyroxine (T4), and thyroidbinding globulin and low levels of reverse triiodothyronine (rT3) The causes and clinical significance of these abnormalities are unknown 11 Skin manifestations The skin manifestations that commonly develop in HIV-infected patients can be grouped into viral, bacterial, fungal, neoplastic, and nonspecific dermatitides Herpes simplex infections occur more frequently, tend to be more severe, and are more likely to disseminate in AIDS patients than in immunocompetent persons Because of the risk of progressive local disease, all herpes simplex attacks should be treated with acyclovir (400 mg orally three times a day until healed, usually 7 days), famciclovir (500 mg orally twice daily until healed), or valacyclovir (500 mg orally twice daily until healed) To avoid the complications of attacks, many clinicians recommend suppressive therapy for HIVinfected patients with a history of recurrent herpes Options for suppressive therapy include acyclovir (400 mg orally twice daily), famciclovir (250 mg orally twice daily), and valacyclovir (500 mg orally daily) Herpes zoster is a common manifestation of HIV infection As with herpes simplex infections, patients with zoster.

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topical clotrimazole (1% cream) as well as hydrocortisone (1% cream) Xerosis presents in HIV-infected patients with severe pruritus The patient may have no rash, or nonspecific excoriations from scratching Treatment is with emollients (eg, absorption base cream) and antipruritic lotions (eg, camphor 95% and menthol 05%) Psoriasis can be very severe in HIV-infected patients Phototherapy and etretinate (025 975 mg/kg/d orally in divided doses) may be used for recalcitrant cases in consultation with a dermatologist Because of the underlying immunodeficiency, methotrexate should be avoided 12 HIV-related malignancies Four cancers are currently included in the CDC classification of AIDS: Kaposi s sarcoma, non-Hodgkin s lymphoma, primary lymphoma of the brain, and invasive cervical carcinoma Epidemiologic studies have shown that between 1973 and 1987 among single men in San Francisco, the risk of Kaposi s sarcoma increased more than 5000-fold and the risk of non-Hodgkin s lymphoma more than tenfold The increase in incidence of malignancies is probably a function of impaired cell-mediated immunity Kaposi s sarcoma lesions may appear anywhere; careful examination of the eyelids, conjunctiva, pinnae, palate, and toe webs is mandatory to locate potentially occult lesions In light-skinned individuals, Kaposi s lesions usually appear as purplish, nonblanching lesions that can be papular or nodular In dark-skinned individuals, the lesions may appear more brown In the mouth, lesions are most often palatal papules, though exophytic lesions of the tongue and gingivae may also be seen Kaposi s lesions may be confused with other vascular lesions such as angiomas and pyogenic granulomas Visceral disease (eg, gastrointestinal, pulmonary) will develop in about 40% of patients with dermatologic Kaposi s sarcoma Rapidly progressive dermatologic or visceral disease is best treated with systemic chemotherapy Liposomally encapsulated doxorubicin given intravenously every 3 weeks has a response rate of approximately 70% -Interferon (10 million units subcutaneously three times a week) also has activity against Kaposi s sarcoma However, symptoms such as malaise and anorexia limit the utility of this therapy Patients with milder forms of Kaposi s sarcoma do not require specific treatment as the lesions usually improve and can completely resolve with antiretroviral therapy However, it should be noted that the lesions may flare when antiretroviral therapy is first initiated probably as a result of an immune reconstitution process (see Inflammatory reactions below) Non-Hodgkin s lymphoma in HIV-infected persons tends to be very aggressive The malignancies are usually of B cell origin and characterized as diffuse large-cell tumors Over 70% of the malignancies are extranodal The prognosis of patients with systemic non-Hodgkin s lymphoma depends primarily on the degree of immunodeficiency at the time of diagnosis Patients with high CD4 counts do markedly better than those diagnosed at a late stage of illness Patients with primary central nervous system lymphoma are treated with radiation Response to treatment is good, but prior to the availability of HAART, most patients died within a few months after diagnosis due to their underlying disease Systemic disease is treated with.

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