Mucocutaneous Candida infections can occur in HIV-infected patients at relatively preserved CD4 cell counts. HIV-infected patients do not usually develop invasive Candida infection unless they have other risk factors, such as neutropenia. Oral candidiasis usually presents as thrush, with mucosal whitish plaques, and can be treated topically (for example, with clotrimazole troches) or with a short course of oral fluconazole. Swallowing symptoms suggest esophageal disease, which requires systemic treatment, such as fluconazole, for a longer course; a lack of treatment response is an indication for endoscopy.
Cryptococcus infection usually presents as subacute meningitis with headache, mental status changes, and fever. Because it often involves the basilar area, cranial nerve deficits may also be seen. The diagnosis can be made most swiftly by antigen testing of cerebrospinal fluid and blood. Management includes antifungal therapy and attention to increased intracranial pressure, which is usually responsible for the morbidity and mortality associated with cryptococcal meningitis.
Mycobacterium avium complex infection usually presents as disseminated disease in patients with CD4 cell counts less than 50/µL; symptoms and signs include fever, sweats, weight loss, hepatosplenomegaly, lymphadenopathy, and cytopenias. Blood cultures for acid-fast bacilli will usually grow Mycobacterium avium complex, but it may also be found on lymph node or liver biopsy when necessary.
Cytomegalovirus most commonly presents with CD4 cell counts less than 50/µL. Cytomegalovirus retinitis, presenting with vision changes or floaters, is much more likely in AIDS than in other immunocompromised conditions, such as after transplantation. Gastrointestinal cytomegalovirus disease is also common, most often as esophagitis or colitis.
Patients with AIDS are also more likely to develop certain malignancies, especially those related to viruses. Non-Hodgkin lymphoma, especially primary central nervous system lymphoma related to Epstein-Barr virus, is significantly increased compared with age-matched controls. Kaposi sarcoma is caused by human herpes virus type 8 and presents as dark red, brown, or violaceous lesions of the skin or mucous membranes; human herpes virus type 8 can also cause primary effusion lymphoma and Castleman disease (giant lymph node hyperplasia). Human papillomavirus–related malignancies are significantly increased in HIV, including cervical and anal cancers, and regular guideline-based screening is important.