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A study on clinical profile of HIV and AIDS patients and find its correlation with [CD.sub.4]+ and [CD.sub.8]+ T lymphocyte levels.

INTRODUCTION: The chronic and incurable infection of the HIV causes insidious erosion of host immune system and gives vent for opportunistic infection and malignancies [1] As per WHO report 2014, 36.9 million people are living with HIV of which 2.0 million are newly infected cases and 1.2 million deaths. The United Nations population Division projects that by the year 2015 the life expectancy at birth in the seven countries in Africa with adult HIV prevalence rate >20% will be 32 years lower on average than the projected life expectancy in the absence of AIDS. [2]

India has the third largest number of people living with HIV in the world-2.1 million at the end of 2013 and accounts for 4 out of 10 people living with HIV in the region. [3] Manipur is the sixth highest HIV prevalent state in India.

The current CDC classification is based on three ranges of [CD.sub.4]+ lymphocyte count and three clinical categories, represented by a matrix of nine mutually exclusive categories. Any HIV infected individual with a [CD.sub.4]+ T cell count of <200/ml has AIDS by definition regardless of the presence of symptoms on opportunistic disease. As the [CD.sub.4]+ T lymphocyte count goes down different opportunistic infections (OTs) occur increasing the mortality and morbidity. The clinical spectrum of diseases caused by opportunistic infections is constantly changing from time to time.

The correlation of [CD.sub.4] T lymphocyte count and distribution of pathogenic or opportunistic infection most commonly found in HIV positive individuals differ from one area to another. Potent antiretroviral therapy (ART) has decreased the incidence, changed the manifestations and improves the outcome of opportunistic infections though Immune Reconstitution Syndrome (IRS) is encountered in some cases as per a report by MACS, HIV treatment coverage is only 36% in India, where 51% of AIDS-related deaths occur. The proportion of people who do not have access to antiretroviral therapy treatment is 64% in India. [4]

So far, few systematic study on clinical profile of OIs and its correlation with [CD.sub.4]+ and [CD.sub.8]+ T lymphocytes among adolescents and adults of Manipur have been done. Therefore the study was taken up with a view to highlight the various modes of clinical presentations of HIV and AIDS with associated OIs with [CD.sub.4]+ and [CD.sub.8]+ lymphocyte levels.

MATERIALS AND METHODS: This hospital based cross sectional study was conducted in the Departments of Medicine, Microbiology, Biochemistry Regional Institute of Medical Sciences over a period of 21 months from Nov. 2004 to July 2006 on 104 HIV infected or AIDS cases above 13 years of age attending OPD and indoor wards of Medicine Department, FACS count center Microbiology Department and ART center of RIMS, selected randomly for the study.

Detailed demographic and clinical data were recorded, meticulous general physical and systemic examinations were done with particular attention to presence of opportunistic infections and the findings were entered in a predesigned Performa.

The diagnosis of HIV/AIDS was done based on the criteria provided by National AIDS Control Organization (NACO, 2000) [5]. After pretest counseling informed consent for HIV testing was taken. For unconscious patients counseling was given to the guardians or spouses of the patients.

3ml of blood was sent to the National Reference Laboratory (NRL) cum Voluntary Confidential Counseling and Testing Centre (VCCTC) Department of Microbiology, RIMS Hospital, Imphal.

Strategy III where 3 ELISA/Rapid/Simple Tests using different principles and Antigens were followed for diagnosis and confirmation of HIV infection. The posttest counseling was done with maintenance of full confidentially. [2]

[CD.sub.4]+ count of the patient were estimated by Fluorescent Activated Cell Sorter (FACS) machine in Department of Microbiology. Relevant samples were sent to Microbiology, Pathology and Biochemistry Departments maintaining strict biosafety measures.

Opportunistic infections were diagnosed based on clinical signs/symptoms, supported by laboratory investigation findings. Supportive and specific treatments were given in each case and outcome recorded. ART was given as per ART guidelines of NACO. These cases were closely monitored and followed up. The discharged cases were followed up during the study period for any mortality.

RESULTS: The data collected was tabulated and analyzed using SPSS version 11.

In our study in 104 HIV/AIDS cases within a period of 21 months, maximum number of cases were in the age group (30-40) years [Table 1] predominantly males 72 (69%) [Table 2] The most common route of infection was injecting drug use (IDU) 64(62%) followed by sexual transmission 31(30%) as shown in [Table 3].

Among the Opportunistic Infections (OIs) tuberculosis was the commonest 40(38%) cases including extra pulmonary tuberculosis contributing 16(15%) cases followed by oral candidiasis 22(21%), cryptococcal meningitis1 5(14%), herpes zoster14(14%), penicillium marneffei 5(5%),cerebral toxoplasmosis 5(5%), cryptosporidial diarrhoea 4(4%), pneumocystis carinii pneumonia (PCP) 3(3%),viral meningitis 2(2%), Kaposi's Sarcoma 1(1%), hairy cell leucoplakia 1(1%) respectively [Table-4].

Other diseases associated with HIV seropositive cases under study were acute gastroenteritis -15(14%), alcoholic liver disease-9(9%), portal HTN-9(9%), peptic ulcer syndrome-8(8%), focal neurological deficit-6(6%), cirrhosis-3(3%), type II diabetes mellitus-1(1%), drug induced hepatitis-1(1%), malena-1(1%), chronic sinusitis-1(1%), epilepsy-1(1%) and deep vein thrombosis of leg 1(1%) respectively [Table-5]. Most of the cases 65(63%) and predominantly males had serum protein in the range (6.1-8.0) gm% [Table-6].

The serum level of Alanine Transaminase (ALT/SGPT) of most of the cases 36(34%) were in the range (30-65) U/L; 26 (25%) cases had SGPT in the range (100-200)U/L and even 200 and above units in 5(5%) [Table7]. When categorized into different [CD.sub.4] range groups majority of the cases had [CD.sub.4]+ T lymphocyte count between (100-200)cells/ of which 19(18%) were males and 10(9%) were females and 28(27%) predominantly males had [CD.sub.4] count<50cells/[micro]l. There was only 1 case with [CD.sub.4] count>500 cells/[micro]l [Table 8].

A look into the various levels of CD 8+T lymphocyte among the HIV seropositive cases showed that maximum no. of cases had CD8 levels in the range (400-600) cells/ul. There were (7%) cases with CD8 + lymphocyte count <200; 18(17%) cases had (200-400) cells/ul. We found 21(20%), 9(9%), 12(12%) 6(6%), 5(5%) and 4(4%) cases having CD8+ lymphocytes in the ranges (600-800), (800- 1000), (1000-1200), (1200-1400), (1400-1600) and above 1600 cells /[micro]l respectively [Table-9]. A correlation is found to exists between CD4+ T lymphocyte and serum total protein with Karl Pearson's correlation coefficient (r=0.270), highly significant at 0.01 level of significance [Table-10].

The level of CD4+T lymphocytes were examined among the various study subjects when the OIs were manifested. It was observed that 15(14%) of the total cases were found to be suffering from cryptococal meningitis and all of them had CD4+T lymphocytes <200; 14(13%) of the cases were even less with cell count <200. Extra pulmonary tuberculosis was occurred in 16(15%) cases and all of them had C4 +T lymphocyte below 400; 13(12%) of which with CD4+T lymphocytes count <200. All subjects with pulmonary tuberculosis except 1(1%) case had CD4+T lymphocyte count below 400 out of which 21(20%) had count below 200. Herpes zoster case 14(14%) except for 1(1%) were found to have CD4+T lymphocyte count below 400 and out of which 10(10%) cases had cell count below 200. Oral candidiasis 22(21%) cases had CD4+T lymphocyte below 400 and 20(19%) of the cases had CD4+T lymphocyte below 200.

Hepatitis C co infection was present in 24(23%) of total cases and all had cell count below 400 and 22(21%) of the cases had even below 200. Hepatitis B co infection occurred in 11(11%) of cases. All cases were found to have CD4+T lymphocytes cell count below 400 and 9(9%) of k the cases had even less than 200. 5(5%) of total cases had cerebral toxoplasmosis with cell count below 400 and 4(4%) of the cases had CD4+T lymphocyte below 200. Penecillium marneffei and lower respiratory tract infection were found to be equally common among the study subjects 5(5%) each. All patients with penicillium marneffei had CD4+T lymphocyte count below 400, 4(4%) of them had count even below 200, while the later 4(4%) of the cases was found to have [CD.sub.4] count below 400 and even 200. Cryptosporidial diarrhea 4(4%), Pneumocystis carinii pneumonia (PCP) associated cases 3(3%) cases had cell count <200. Viral meningitis and cytomegalovirus (CMV) 2(2%) cases had CD4 count <200. Viral fever, Kaposi's sarcoma and Hairy cell leucoplakia 1(1%) each had CD4+ T lymphocyte count <400[Table-11].

DISCUSSION: Out of a total of 104 HIV seropositive patients included in this 21 months study from November 2004 to July 2006 maximum number of cases were in the age group 30-40 years (55 cases) which is the sexually active and in reproductive age group. Unemployment, frustrations and habit of testing or abusing drugs could also be important additional factors.

The associated risk factors were IDUs 64(62%), sexual transmission 31(30%), blood transfusion 4(4%) and unknown 5(5%). Easy availability of such narcotic substances like heroin which can be abused intravenously and sexual transmission of the disease to their partners are causes of HIV infection. Pulmonary tuberculosis 24(23%) cases, oral candidiasis 22(21%) followed by extra pulmonary tuberculosis 16(15%) were the frequent OIs encountered. Our findings are in agreement with the findings of Ayyagari A et al. [6]

The incidence of TB in HIV infected persons is more than 100 times that of the general population and unlike other opportunistic infections, TB can occur at an early stage of HIV infection with pulmonary features and also in late stages with more extra pulmonary presentations [7] Cryptococcal meningitis occurred in 15(14%) of the cases where as a greater figure was observed by Singh PN et al where tuberculosis and Cryptococcus's were the first and second common Ols in the south East Asia. [8]

Skin infections like Herpes zoster occurred in 14(14%) cases. The common co-infections seen were Hepatitis B-11(11%) cases and Hepatitis C-24(23%) cases. This is caused by sharing of needles by the IDUs. Alcoholic fatty liver and cirrhosis of liver were associated in 9(9%) cases and 3(3%) cases respectively. Cerebral toxoplasmosis occurred in 5(5%) of the cases which is a lower figure compared to findings of Nissapatron V et.al [9] where 226 out of 505 patients suffered from toxoplasmosis, 27 with toxoplasma encephalitis and 199 without encephalitis.

Penicillium marneffei, an important OI accounts for 5(5%) of the study population though it was the third most common OI in South East Asia after TB and Cryptococcus's as reported by Singh PN et at. [8] Pneumocystis carinii pneumonia (PCP) shared 3(3%) and it is supported by other authors, [10] where PCP was the most common parasite and ubiquitous extracellular protozoa which proliferates easily in the immune compromised patients.

Cryptosporidial diarrhoea claims 3(3%) of the total cases which is comparable to other studies. [11] Viral meningitis occurred in 2(2%) cases. This could be attributed to their immune compromised states during which viral infection was very common among the masses.

Cytomegalovirus (CMV) infection occurred in 2(2%) contrast to a larger figure found by other authors. [12] where the most frequent OIs were mycobacterium avium complex, pneumocystis carinii pneumonia and cytomegalovirus retinitis.

Focal neurological deficit in the form of paralysis of one side of body (Hemiparesis) with cranial nerve palsy accounting for 6(6%) or one limb (Monoparesis) accounting for 2(2%). These patients had cerebral infections like cryptococcal meningitis and tubercular meningtits. Kaposi's sarcoma, hairy cell leukoplakia were other associated health problems.

The moderately raised SGPT level in many cases could be attributed to Hepatitis B virus, Hepatitis C Virus co-infection and chronic alcohol use. Further analysis showed 28(27) HIV seropositive cases has [CD.sub.4]+ T lymphocyte cell count below 50/cumm which was the highest percentage. Lack of awareness, late diagnosis could be the reason. Maximum no. of cases 22(20%) had [CD.sub.8]+ T lymphocyte range (400-600)/[micro]l of blood.

A look into the distribution of HIV seropositive cases with respect to [CD.sub.4]+T lymphocytes cell count and major opportunistic infections showed pulmonary TB and Hepatitis C virus 24(23%) stand highest followed by oral candidiasis 22(21%), Extra pulmonary Tuberculosis 16(15%) and Cryptococcal meningitis 15(14%). The maximum number of pulmonary tuberculosis patients manifest when CD4+T lymphocyte count is below 100, indicating that higher incidence of OI occur with lower level of CD4+T lymphocyte count although the opportunistic infections are different in various geographical regions. [13] In America and Europe the pueumocystis carinii pneumonia, cryptococcal meningitis, CMV infection and toxoplasmosis are common but in developing countries like Africa and India tuberculosis and other tropical parasitic infections are predominant.

Analysis of CD8+T lymphocyte count of HIV+ cases and major opportunistic diseases reveals that maximum number of cases with pulmonary tuberculosis have CD8+T lymphocyte cell count less than 400[micro]l and the most of oral candidiasis cases have CD8+T lymphocytes cell count between (600-800)/[micro]l. Next was extra pulmonary tuberculosis whose maximum number falls in the interval (400-600)/[micro]l whereas cryptococcal meningitis cases had cell count below 400[micro]l. The relation between OI and CD8+T lymphocyte cell count is insignificant.

The serum level of total protein varies positively with the level of CD4+T lymphocyte cell count significantly as the value of t-statistics is (2.941) with P<0.01 when r =0.270 but the variation in the level of total protein may not be due to variation in the level of CD8+T lymphocyte cell court with the Karl pearson coefficient of correlation r = 0.043. The value of 't' was found to be insignificant (t=0.435).

CONCLUSION: In our study in 104 HIV/AIDS cases within 21 months maximum no of cases were in the age group (30-40) years and the most common route of transmission was IDU i.e. 64(62%) followed by sexual transmission 31(30%) tuberculosis was the most common opportunistic infection 40(38%) cases including extra pulmonary tuberculosis 16(15%) cases, followed by oral candidiasis, cryptococcal meningitis herpes zoster 14(14%), penicillium marneffei 5(5%), cerebral toxoplasmosis 5(5%), cryptosporidial diarhoea (C. parvum) 4(4%) pneumonystis carinii pneumonia (PCP) 3(3%), Kaposi's Sarcoma1(1%), hairy cell leukoplakia 1(1%). Co infection with Hepatitis B Viral and hepatitis C virus were 11(11%) and 24(23%) cases respectively as IDU is still the commonest route of transmission in Manipur. Most of the OIs occured in patients having CD4 count less than 100/ml i,e 83(79%) cases expect in a case of pulmonary tuberculosis and one case of herpes zoster with CD4+ T lymphocyte above 400/ml. Increase in serum SGPT could be due to Hepatitis B, Hepatitis C co infection and chronic alcohol use. A significant positive correlation exists between CD4+T lymphocyte and serum total protein. Out of 104 cases, 68 cases were under antiretroviral drugs and 14 of such cases developed OIs again. Hence, there is possibility of treatment failure on fist line antiretroviral drug treatment and in these cases further study is required.

DOI: 10.14260/jemds/2015/1858

REFERENCES:

[1.] Barlett J: Natural history of HIV infection, the John Hopkins hospital guides to medical care of patients with HIV infection; Williams and Wilkins, Baltimore Maryland, USA, 4:19-25, 1994.

[2.] Fauci AS and Lane HC: Human Immunodeficiency Virus (HIV) disease, AIDS and related disorders, Harrison's Principles of Internal Medicine, Eugene Braunwald, MC Graw Hill, New Delhi. 16 Edn, 2, 1076-1139, 2005.

[3.] Manipur AIDS control Society. Manipur AIDS control Society rebuts CAG report on HIV positive cases rising to 40,855. Manipur; MACS, August 2014 [online]. Available at: http//www.dnaindia.com/india. (Assessed 14/8/15).

[4.] WHO, UNAIDS AND UNICEF Global summary of the AIDS epidemics, 2014. Geneva WHO July 2015 [Online]. Available at: http://www.who.int/hiv/data/epicrore-july2015.png? ua=1 (Asessed 10/8/15).

[5.] National AIDS Control Organisation (NACO) as on 31st July, 2005. (Available at http: //www.naco.nic.in/indiascene/over.html).

[6.] Ayyagari A, Sharma AK, Prasad KN, Dhole TN, Kishore J and Chaudhari G: Spectrum of opportunistic infection in Human Immunodeficiency Virus (HIV) infected cases in a tertiary care hospital, Indian Journal of Medical Microbiology; 17:78-80, 1999.

[7.] Decker CF and Lazarus A: Tuberculosis and HIV infection, Post Graduate Medicine: 1 (10): 28-41, March 2001.

[8.] Singh PN, Khuraijam R, Singh Y, Singh IK, Sharma SS, Singh MK, Singh YN, Chakrabarti A, Pathue A, Kaufman L and Ajillo L: Indigenous Disseminated Penicillium Marneffei Infection in the state of Manipur, India. Report of four Autochthonous cases, Journal of Clinical Microbiology; Vol 37 (8): 2699-2702 Aug 1999.

[9.] Nissapatron V, Lee C, Quek KF, Leong CL, Mahmud R and Abdullah KA: Toxoplasmosis in HIV/AIDS patients; a current situation, Jpn J infect dis: Vol 57(4): 160-5, 2004.

[10.] Mathew R and Galwalkar S: Pneumocystis carinii pneumonia (PCP) in HIV patients, The Indian practitioner, 52 (9): 639-642, 1999.

[11.] Mohandas K, Sehgai R, Sud A and Malla N: Prevalence Intestinal Parastic pathogens in HIV-Seropositive Individual in Northern India, Jpn, J.J Infectious diseases; 55:83-84, 2002.

[12.] Jones JL, Hanson DL, Dworkin MS, Kaplan JE and Ward JW: Trends in AIDS related opportunistic infections among men who have sex with men and among injecting drug users, 1991-1996. J Infect Dis; 178(1):114-20, 1998.

[13.] Joshi PL and Mishra SN: Opportunistic and HIV/AIDS associated infections: An overview, Manual on laboratory diagnosis of common opportunistic infections associated with HIV/AIDS; Baveja UK and Sokhey J, National Institute of communicable disease (NICD), Directorate General of Health Services, Government of India and National AIDS Control Organisation (NACO), Ministry of Health and family welfare, Govt. of India; 3-4, 1999-2000.

Moirangthem Ratankumar Singh (1), Suchitra Chongtham (2), Thongam Bhimo Singh (3)

AUTHORS:

(1.) Moirangthem Ratankumar Singh

(2.) Suchitra Chongtham

(3.) Thongam Bhimo Singh

PARTICULARS OF CONTRIBUTORS:

(1.) Assistant Professor, Department of General Medicine, Jawaharlal Nehru Institute of Medical Sciences, Imphal, East.

(2.) Assistant Professor, Department of Biochemistry, Jawaharlal Nehru Institute of Medical Sciences, Imphal, East.

(4.) Professor, Department of General Medicine, Regional Institute of Medical Sciences, Imphal, West.

FINANCIAL OR OTHER COMPETING INTERESTS: None

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Moirangthem Ratankumar Singh, Jawaharlal Nehru Institute of Medical Sciences, Porompat-795001, Imphal East. E-mail: drmratan2007@gmail.com

Date of Submission: 26/08/2015. Date of Peer Review: 27/08/2015. Date of Acceptance: 07/09/2015. Date of Publishing: 12/09/2015.
Table 1: Distribution of the HIV seropositive cases with respect to
age

Age (years)    No. of Cases (1%)

14-20                1 (1)
20-30               16 (15)
30-40               55 (53)
40-50               27 (26)
50 and above         5 (5)
Total              104 (100)

Table 2: Distribution of HIV seropositive cases with respect to sex

Sex      No. of Cases (%)

Male          72(69)
Female        32(31)

Total 104(100).

Table 3: Distribution of HIV seropositive cases with respect to risk
factors

Risk factor                                  No. of Cases (%)

IDU                                               64(62)
Sexual transmission                               31(30)
Blood transfusion                                  4(4)
(Before imposition of mandatory screening)
Unknown                                            5(5)

Total 104(100).

Table 4: Distribution of HIV seropositive cases with respect to
opportunistic infections(OI) and co-infection

Opportunistic Infection and Co-infection   No. of Cases (%)

Cryptosporidial diarrhea(C parvum)               4(4)
Cryptococcal meningitis                         15(14)
Tuberculosis:
(i) Extrapulmonary                              16(15)
(ii) Pulmonary                                  24(23)
Pneumocystis carinii pneumonia(PCP)              3(3)
Cerebral toxoplasmosis                           5(5)
Penicillium marneffei                            5(5)
Herpes zoster                                   14(14)
Viral meningitis                                 2(2)
Oral candidiasis                                22(21)
Hepatitis B virus                               11(11)
Hepatitis C virus                               24(23)
Cytomegalovirus infection (CMV)                  2(2)
Kaposis's sarcoma                                1(1)
Hairy cell leukoplakia                           1(1)

Table 5: Distribution of HIV seropositive cases with respect to
associated diseases

Associated Diseases            No. of Cases (%)

Acute gastroenteritis(AGE)          15(14)
Alcoholic liver disease(ALD)         9(9)
Portal hypertension                  9(9)
Peptic ulcer syndrome(PUS)           8(8)
Focal neurological deficit:
(i) Rt VI nerve palsy                1(1)
(ii) VII nerve palsy                 2(2)
(iii) VIII nerve palsy               1(1)
(iv) Right hemiparesis               2(2)
Cirrhosis                            6(6)
Type II diabetes mellitus            3(3)
Drug induced hepatitis               1(1)
Malena                               1(1)
Chronic sinusitis                    1(1)
Epilepsy                             1(1)
Deep vein thrombosis of leg          1(1)

Table 6: Distribution of HIV seropositive cases with respect to sex
and total protein (gm %)

Total protein          Sex              Total(%)

                Male (%)   Female (%)
[less than or    17(16)     7(7)         24(23)
equal to] 6.0
6.1-8.0          47(46)     18(17)       65(63)
Above 8.0         8(7)       7(7)        15(14)
Total            72(69)     32(31)       104(100)

Table 7: Distribution of HIV seropositive cases with respect to
SGPT(U/L)

                              Sex

SGPT (U/L)      Male (%)   Female (%)   Total (%)

Below 30          8(8)        8(8)       16(16)
30-65            24(23)      12(11)      36(34)
65-100           16(15)       5(5)       21(20)
100-200          21(20)       5(5)       26(25)
200 and above     3(3)        2(2)        5(5)
Total            72(69)      32(31)     104(100)

Table 8: Distribution of HIV seropositive cases with respect to CD4+T
lymphocyte count(cell/ul)

                                  Sex               total

CD4+T- Lymphocyte count    Male (%)   Female (%)

Below 50                    2(21)        6(6)       28(27)
50-100                      20(19)       4(4)       24(23)
100-200                     19(18)      10(9)       29(27)
200-300                      7(7)        7(7)       14(14)
300-400                      3(3)        3(3)        6(6)
400-500                      1(1)        1(1)        2(2)
500 and above                 -          1(1)        1(1)
Total                       72(69)      32(31)     104(100)

Total 72(69) 32(31) 104(100).

Table 9: Distribution of the HIV seropositive cases with respect to
CD8 +T-lymphocyte cell count

                                      Sex

CD8+ T-lymphocyte cell count   Male (%)   Female (%)   Total (%)

Below 200                        4(4)        3(3)        7(7)
200-400                         16(15)       2(2)       18(17)
400-600                         15(14)       7(6)       22(20)
600-800                         16(15)       5(5)       21(20)
800-1000                         5(5)        4(4)        9(9)
1000-1200                        6(6)        6(6)       12(12)
1200-1400                        4(4)        2(2)        6(6)
1400-1600                        4(4)        1(1)        5(5)
1600 and above                   2(2)        2(2)        4(4)

Total 72(69) 32(31) 104(100).

Table 10: Correlation Table

                                 CD4      Total Protein

CD4 Pearson Correlation,r         1         .270 (**)
t                                             2.941
Sig.(2-tailed)                                .006
n                                104           104
Total Pearson Correlation,r   .270 (**)         1
Protein t                       2.941
Sig.(2-tailed)                  .006
n                                104           104

** Correlation is significant at the 0.01 level (2-tailed).

Table 11: Distribution of the HIV seropositive cases with respect to
CD4+T-lymphocyte cell count(cell/ul) and major OIs and co-infections

     Major OI and co-infection CD4+ T lymphocyte cell count
                                  Below 100   100-200   200-400

Cryptococcal meningitis            11(10)      3(3)      1(1)
Extrapulmonary tuberculosis         6(6)       7(6)      3(3)
Pulmonary tuberculosis             14(13)      7(7)      2(2)
Herpes zoster                       6(6)       4(4)      3(3)
Oral candidiasis                   13(12)      7(7)      2(2)
Hepatitis B                         5(5)       4(4)      2(2)
Hepatitis C                        15(14)      7(7)      2(2)
Cerebral toxoplasmosis              4(4)        --       1(1)
Penecillium marneffei               2(2)       2(2)      1(1)
Cryptosporidial diarrhea            3(3)       1(1)       --
Pneumocystis carinii pneumonia      1(1)       2(2)       --
Cytomegalovirus infection (CMV)     1(1)       1(1)       --
Kaposi's sarcoma                    1(1)        --        --
Hairycell leukoplekia               1(1)        --        --

 Major OI and co-infection CD4+ T lymphocyte cell count
                                  400 and above   Total

Cryptococcal meningitis                --         15(14)
Extrapulmonary tuberculosis            --         16(15)
Pulmonary tuberculosis                1(1)        24(23)
Herpes zoster                         1(1)        14(14)
Oral candidiasis                       --         22(21)
Hepatitis B                            --         11(11)
Hepatitis C                            --         24(23)
Cerebral toxoplasmosis                 --          5(5)
Penecillium marneffei                  --          5(5)
Cryptosporidial diarrhea               --          4(4)
Pneumocystis carinii pneumonia         --          3(3)
Cytomegalovirus infection (CMV)        --          2(2)
Kaposi's sarcoma                       --          1(1)
Hairycell leukoplekia                  --          1(1)
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Title Annotation:ORIGINAL ARTICLE
Author:Singh, Moirangthem Ratankumar; Chongtham, Suchitra; Singh, Thongam Bhimo
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Sep 14, 2015
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