HIV INFECTIONS
Ed Friedlander, M.D., Pathologist
scalpel_blade@yahoo.com

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Welcome to Ed's Pathology Notes, placed here originally for the convenience of medical students at my school. You need to check the accuracy of any information, from any source, against other credible sources. I cannot diagnose or treat over the web, I cannot comment on the health care you have already received, and these notes cannot substitute for your own doctor's care. I am good at helping people find resources and answers. If you need me, send me an E-mail at scalpel_blade@yahoo.com Your confidentiality is completely respected. No texting or chat messages, please. Ordinary e-mails are welcome.

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I'm still doing my best to answer everybody. Sometimes I get backlogged, sometimes my E-mail crashes, and sometimes my literature search software crashes. If you've not heard from me in a week, post me again. I send my most challenging questions to the medical student pathology interest group, minus the name, but with your E-mail where you can receive a reply.

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Pathology's modern founder, Rudolf Virchow M.D., left a legacy of realism and social conscience for the discipline. I am a mainstream Christian, a man of science, and a proponent of common sense and common kindness. I am an outspoken enemy of all the make-believe and bunk that interfere with peoples' health, reasonable freedom, and happiness. I talk and write straight, and without apology.

Throughout these notes, I am speaking only for myself, and not for any employer, organization, or associate.

Special thanks to my friend and colleague, Charles Wheeler M.D., pathologist and former Kansas City mayor. Thanks also to the real Patch Adams M.D., who wrote me encouragement when we were both beginning our unusual medical careers.

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Especially if you're looking for information on a disease with a name that you know, here are a couple of great places for you to go right now and use Medline, which will allow you to find every relevant current scientific publication. You owe it to yourself to learn to use this invaluable internet resource. Not only will you find some information immediately, but you'll have references to journal articles that you can obtain by interlibrary loan, plus the names of the world's foremost experts and their institutions.

Alternative (complementary) medicine has made real progress since my generally-unfavorable 1983 review. If you are interested in complementary medicine, then I would urge you to visit my new Alternative Medicine page. If you are looking for something on complementary medicine, please go first to the American Association of Naturopathic Physicians. And for your enjoyment... here are some of my old pathology exams for medical school undergraduates.

I cannot examine every claim that my correspondents share with me. Sometimes the independent thinkers prove to be correct, and paradigms shift as a result. You also know that extraordinary claims require extraordinary evidence. When a discovery proves to square with the observable world, scientists make reputations by confirming it, and corporations are soon making profits from it. When a decades-old claim by a "persecuted genius" finds no acceptance from mainstream science, it probably failed some basic experimental tests designed to eliminate self-deception. If you ask me about something like this, I will simply invite you to do some tests yourself, perhaps as a high-school science project. Who knows? Perhaps it'll be you who makes the next great discovery!

Our world is full of people who have found peace, fulfillment, and friendship by suspending their own reasoning and simply accepting a single authority that seems wise and good. I've learned that they leave the movements when, and only when, they discover they have been maliciously deceived. In the meantime, nothing that I can say or do will convince such people that I am a decent human being. I no longer answer my crank mail.

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More of Ed's Notes: Ed's Medical Terminology Page

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Medical Dictionary

Courtesy of CancerWEB

STUDY OBJECTIVES

Name and describe the AIDS virus(es). Outline the essential lesions in AIDS. Tell what tissues the virus specifically attacks, and describe the anatomic pathology, the usual labs for diagnosis and monitoring, and the key molecules.

Describe the natural course of HIV infection. Tell what viral and host factors might affect transmission and rate of progression. Tell what we know about true non-progressive and slowly-progressive HIV infection.

Describe Kaposi's "sarcoma", as seen in AIDS patients, and the name and family of the virus that causes it. Describe the other quasi-cancers in these patients.

Name and describe the other common infections in AIDS patients. List characteristics common to these infections.

Describe the nervous system changes in HIV infection, and explain the basis of HIV-related problems with hemostasis.

Tell who is at high risk, who is at low risk, and who is at minimal risk for AIDS. Explain how to test for AIDS virus.

Describe in human terms the effect of the AIDS epidemic.

No quizbank for this unit. We usually think of good questions together at the end of the lecture.

AIDS
First Section
Chaing Mi, Thailand

AIDS
Second Section
Chaing Mi, Thailand

Immune Disease
Iowa Virtual Microscopy
Have fun

Neuropathology of HIV infection
Nice photos and article
Temple U.

Pathology of HIV Infection
WebPath Tutorial

HIV itself
WebPath Tutorial

KCUMB Students
"Big Robbins" -- Immuno
Lectures follow Textbook

While [Noam] Chomsky insisted "We must act as sensitive and responsible human beings", [Michael] Foucault replied that such ideas as responsibility, sensitivity, justice, and law were merely "tokens of ideology" that completely lacked legitimacy.

HIV INFECTION ("AIDS", "acquired immunodeficiency syndrome", retroviral immunodeficiency, "slim disease", etc., etc.) pathology Arch. Path. Lab. Med. 114(3), Whole issue, March 1990 (still great); updates Ann. Int. Med. 134: 761 & 978, 2001; J. Allerg. Clin. Imm. 110: 3, 2002; molecular pathogenesis of the immunodeficiency Nat. Med. 9: 854, 2003. All still good.

INTRODUCTION

AIDS, the full manifestation of HIV infection, is a devastating infectious disease that has been very much with us since the late 1970's.

{37378} HIV giant-cell encephalitis

HIV-induced encephalopathy

Yutaka Tsutsumi MD

AIDS and the brain
Radiology-Pathology
Uniformed Services

{05255} AIDS iceberg
{05256} AIDS iceberg

INFECTIONS

{37484} pneumocystosis (silver has stained these black)

Pneumocystis carinii
H&E, see the froth
KU Collection

{05272} herpes around the anus in AIDS

{42046} tuberculosis (the bugs are stained red)

AIDS / CNS lymphoma /
Mycobacterium avium complex
Pittsburgh Pathology Cases

{18817} cryptosporidiosis (the bugs stain pale blue and are in the brush border, see 'em?)

Bartonellosis
Bacillary angiomatosis in AIDS
Yutaka Tsutsumi MD

KAPOSI'S SARCOMA (review NEJM 342(14), April 6, 2000.)

{05270} Kaposi's "sarcoma" in AIDS
{05257} Kaposi's in AIDS
{32447} Kaposi's, foot

Kaposi's
NCI
Wikimedia Commons

Kaposi's sarcoma in AIDS

Yutaka Tsutsumi MD


{32448} Kaposi's, ankle
{18816} Kaposi's, histology (weird vessels, especially notice the red cells between the spindle cells)

Kaposi's sarcoma
AIDS patient
KU Collection

Kaposi's sarcoma
Photomicrograph
KU Collection

MALIGNANT LYMPHOMAS (today's work Arch. Path. Lab. Med. 137: 360, 2013)

NERVOUS SYSTEM DAMAGE (Arch. Neuro. 54: 846, 1997; South. Med. Assoc. J. 94: 266, 2001)

{05309} AIDS, brain atrophy

OTHER SYMPTOMS AND SIGNS

IMMUNOLOGY

THE AIDS VIRUSES ("HIV-1", "HIV-2")

{00448} HIV

ARC ("AIDS-related complex") -- still a useful distinction

ANATOMIC PATHOLOGY OF HIV INFECTION

{23350} AIDS, atrophy of lymphoid tissue (trust me that this was a lymph node)
{05258} AIDS cachexia

{20228} end-stage lymph node, AIDS; this used to be a lymph node, but almost all the lymphocytes are gone

HIV lymphadenopathy

Yutaka Tsutsumi MD

HIV TESTING

AT RISK

HIV INFECTIONS IN MSM's

AT FAR LESS RISK....:

THE IMPACT OF AIDS (update NEJM 347: 357, 2002)

FIRST: There are seven things that clearly reduce the transmission of AIDS.

    1. HIV testing of blood products for transfusion / artificial coagulation factors for those in need
    2. Anti-retroviral prophylaxis before and during childbirth
    3. Condom distribution and use (update Lancet 380: 424, 2012)
    4. Needle exchange programs
    5. Male circumcision
    6. Formula feeding instead of breast feeding by HIV-positive mothers
    7. Early antiretroviral treatment for an HIV-positive member of a serodiscordant couple (now proved: NEJM 365: 493, 2011)
THE NUMBERS

HIV IN THE UNITED STATES

HIV IN AFRICA

NATION BY NATION

IS MY TRANSFUSION SAFE?

DOCTORING

POP CLAIMS

THE MONEY -- THEN AND NOW

AIDS requires early intervention with costly therapeutic agents. And ironically, it increasingly affects those least able to pay for care. The epidemic thus forces us to think more clearly about the issue of health care as a right. We cannot resolve the question of what kind of health care should be provided to patients with HIV infection if we do not also determine what care all citizens deserve when they are ill.

        -- Ronald Bayer, M.D., Columbia
        Hosp. Pract. Feb. 15, 1994

BARRIER PROTECTION / SAFE SEX / NEEDLE EXCHANGES

THE SEARCH FOR AN HIV VACCINE

SPECIFIC THERAPIES FOR HIV INFECTION

    The AIDS drugs:

    • Nucleoside reverse transcriptase inhibitors
    • Non-nucleoside reverse transcriptase inhibitors
    • Protease inhibitors
    • Integrase inhibitors
    • Entry / fusion inhibitors

    Being infected with HIV, while still very serious, is no longer a death sentence. This is due to the success of reverse transcriptase inhibitors combined with the anti-HIV-proteases (saquinavir, etc.): Nature 374: 494, 1995, Lancet 345: 902, 1995; design-your-own (Proc. Nat. Acad. Sci. 92: 3298, 1995); ritonavir NEJM 333: 1534, 1995. The triumph of the combination of saquinavir, zidovudine, and zalcitabine: NEJM 334: 1011, 1996. "HAART" (highly active anti-retroviral therapy) renders HIV infection non-progressive, and can sometimes clear the blood of the infectious agent. Protease inhibitor review: JAMA 277: 145, 1997. The protease inhibitors: Arch. Int. Med. 157: 951, 1997; NEJM 338: 1281, 1998. Combination therapy Am. J. Med. 102: 76, 1997. Review of the current successes (mortality cut by over 2/3): NEJM 338: 853, 1998. How T-cells repopulate when HAART begins: Nat. Med. 4: 208, 1998. People with private insurance were more likely to get the new drugs than people on welfare, and there was amazingly little outcry from militants over this -- perhaps they sense changing public attitudes about entitlement.

Magic Johnson

Stay tuned for much, much more on HIV infections in the coming years! There will be new opportunistic infections, new strains of the virus, new medications, new player-molecules, and new approaches to the whole business of getting people treated.

At this time, a mega-review from McMaster indicates exactly no real evidence of the effectiveness of any "alternative / complementary" remedy for AIDS, with the possible exception of some subjective relief from common stress-management (Int. J. STD & AIDS 16: 395, 2005).

BIBLIOGRAPHY / FURTHER READING

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Teaching Pathology

Pathological Chess


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