Profile and Pattern of Prolonged Fever among HIV Infected Adult People at Vivekananda Memorial Hospital, Sargur, H D Kotetaluk, Mysore, Karnataka

Background: Prolonged fever is a common clinical problem in HIV infected patients, especially in those with advanced HIV. In India where ART is provided on the basis of CD4 count and WHO clinical stage and not all eligible HIV patients are on ART or co-trimoxazole prophylaxis and vast majority of medical centers lack laboratory facilities to perform invasive and specialized diagnostic tests, clinicians need an alternative approach. In this study we propose use the diagnostic algorithm for prolonged fever developed and validated by CMC Vellore in a resource poor setting and determine its utility to identify causes of prolonged fever among HIV infected patients in a hospital setting and correlate with CD4 count, WHO staging and ART status. Objectives: a) To identify the causes of prolonged fever among HIV infected patients using the CMC algorithm; b) To correlate causes of fever in relation to CD4 count, WHO staging and ART status; and c) To assess the utility of the algorithm developed by CMC Vellore for evaluation of prolonged fever in a resource poor setting Methods: Prospective longitudinal observational study conducted on convenient sample of 90 consecutive HIV infected patients presenting with prolonged fever at a secondary care hospital for specialized care of HIV disease. Results: Ninety patients were included and in 82 (91.1%) patients causes of fever were able to be diagnosed by CMC algorithm. TB meningitis was the most common cause of fever accounting for 23.3% followed by Bacterial pneumonia, Pulmonary TB and Pneumocystis jirevoci pneumonia accounting for 13.3%, 11.1% and 13.3% respectively. Cryptococcal meningitis and various forms of extra pulmonary tuberculosis were the third common cause in 7.7% and 11% patients. Paradoxical IRIS-TBM was causing fever in 3 patients and pyomyositis in 2 patients. Protozoan infections Amebic colitis and cryptosporidiasis, Cryptococcal pneumonia, Neurosyphilis, Non-Hodgkins lymphoma, Toxoplasmosis and Urinary tract infection were the cause of fever in one each of patients. Tuberculosis continues to be the most common cause of prolonged fever(58.8%) in this cohort of Indian patients infected with HIV although the prevalence rates seems to be decreased compared to the Pre-HAART era studies from India(71%,10 69%7). Extra pulmonary TB continues to be the predominant form of TB and in this study the most common form was TB meningitis. Pneumocystis pneumonia, Cryptococcal meningitis and toxoplasmosis continues to be prevalent in same proportion as in previous studies underlining the late diagnosis of HIV infection among the general population and initiation of ART at lower CD4 counts among diagnosed people. CD4 count and WHO staging were found to be the statistically significant factors in determining the cause of fever and ART status was not statistically significant. This underlines the importance of CD4 count and clinical staging as per WHO staging during evaluation of symptomatic HIV disease in resource poor settings even though sophisticated tests like HIV viral load and PCR for diagnosis of Opportunistic infections are becoming more and more affordable and accessible.