AIDS/HIV Advice to the Diver

Benefits of Diving

Studies have shown that sports participation benefit the HIV/AIDS person both mentally and physically. (See References below). Benefits actually include a delay in the progression of HIV morbidity among participants in the sports group. There can be improvement in cardiac capacity among participants; and a positive correlation between physical training and psychological parameters. Psychological tests show that sports activities cause a reduction in depression, fatigue, and anger, an increase in vigor and an obvious improvement in the quality of life of HIV-infected persons and AIDS patients.

Factors Adverse to Diving

Physical Effects of AIDS
The AIDS-related complex (ARC) is a constellation of chronic symptoms and signs manifested by HIV-infected persons who have not had the opportunistic infections or tumors that define AIDS. These symptoms, signs, and laboratory abnormalities include generalized lymphadenopathy, weight loss, intermittent fever, malaise, fatigue, chronic diarrhea, leukopenia, anemia, immune-mediated thrombocytopenia, oral hairy leukoplakia, and oral thrush (candidiasis). A severe manifestation of ARC is the wasting syndrome (called slim disease in Africa), which is characterized by progressive weight loss >= 15% body wt.
Neurologic symptoms often are the first manifestation of AIDS and commonly occur during its course. Neurologic disorders include acute and chronic aseptic meningitis, peripheral neuropathies with weakness and paresthesias, and encephalopathy with seizures, with focal motor, sensory, or gait deficits, and with progressive dementia. Infections, neoplasms, vascular complications, aseptic meningitis, and neuropathy are among the more prominent sequelae.

A serious neurologic complication is a subacute encephalitis caused by either HIV or cytomegalovirus. The gray matter exhibits nodular collections of microglial cells without other inflammatory infiltrates. Intranuclear and intracytoplasmic inclusions have been observed within the nodules. Small, poorly defined foci of perivenular demyelination are found in white matter. Memory loss, confusion, psychomotor retardation, myoclonus, seizures, and dementia progressing to coma are typical findings spanning weeks to months prior to death. Cortical atrophy on CT, CSF pleocytosis and elevated protein level, and a diffusely abnormal EEG are often, albeit inconsistently, found but are nonspecific.

Vascular complications: Nonbacterial endocarditis, usually with neoplasm or severe infection, can produce transient ischemic attacks and focal ischemic stroke. Cerebral hemorrhage can occur in thrombocytopenic states (eg, lymphoma, idiopathic thrombocytopenic purpura).

Aseptic meningitis: Rapid onset of headache, fever, stiff neck, and photophobia may be associated with a CSF mononuclear pleocytosis, elevated proteins, slightly depressed glucose, and consistently negative cytologic studies and cultures. The episodes are transient but can be recurrent.

Peripheral neuropathy: Painful dysesthesias, moderate distal sensory loss (stocking-and-glove), depressed ankle reflexes, distal weakness, and atrophy can occur in varying degrees and can coincide with rapid weight loss from poor nutrition; no metabolic cause has been identified. A Guillain-Barré type of neuropathy has been reported. Myopathy similar to polymyositis may complicate AIDS or zidovudine therapy.

A few patients present with renal insufficiency or nephrotic syndrome, with symptomatic anemia, or with immune-mediated thrombocytopenia. HIV-associated thrombocytopenia occurs throughout the full spectrum of HIV infections, usually responds to the same interventions (corticosteroids, splenectomy, IV immune globulin) as idiopathic thrombocytopenic purpura, and seldom leads to bleeding.

Effects and Side-effects of AIDS Drug Regimens
Every drug has certain effects and possible side-effects that vary significantly in each individual.
Multiple drug combinations are being used to suppress the AIDS virus, these medications also have interactions that might affect the diver with HIV/AIDS.

Effects of AIDS-induced Opportunistic Infections and Tumor
AIDS is defined by the development of opportunistic infections and/or certain secondary cancers known to be associated with HIV infection, such as Kaposi’s sarcoma and non-Hodgkin’s lymphoma, especially primary lymphoma of the brain (see Table ). Many patients are first seen with a life-threatening opportunistic infection or malignancy without the preceding symptoms of ARC.
Patterns of specific opportunists vary both geographically and between risk groups. In the USA and Europe, > 90% of AIDS patients with Kaposi’s syndrome (KS) were homosexual or bisexual men, possibly because of an unidentified, sexually transmissible cofactor. Recently the incidence of KS has been diminishing. Most AIDS cases in the USA and Europe (about 60%) present with Pneumocystis carinii pneumonia, which is reported less frequently in Africa. Toxoplasmosis and TB are more common in tropical areas where the prevalence of latent infections with Toxoplasma gondii and Mycobacterium tuberculosis in the general population is high. Even in developed countries where background levels of TB are low, HIV infections have caused increased rates and atypical presentations of TB.

CNS infections: The most common treatable neurologic illness is toxoplasmic encephalitis. Headache, lethargy, confusion, seizures, and focal signs evolve over days to weeks. CT findings include ring-enhancing lesions with a predilection for basal ganglia. Serologic tests for IgG antitoxoplasmal antibodies reflecting previous infection are almost always positive but do not always provide conclusive proof that the lesion is caused by Toxoplasma organisms. The CSF shows a mild to moderate pleocytosis and elevated protein content. Brain biopsy can be diagnostic. Treatment is with pyrimethamine and sulfadiazine (or clindamycin if the patient is allergic to sulfa). Prognosis is at best guarded, since recurrence is possible and other complications of AIDS are likely. Cryptococcal and tuberculous meningitides (Mycobacterium avium-intracellulare) also occur in AIDS. Progressive multifocal leukoencephalopathy and infections with Candida, Aspergillus, and gram-negative organisms occur less frequently.

Neoplasms: Primary CNS lymphoma is a frequent intracranial mass lesion in AIDS. It may be clinically silent or may produce focal signs consistent with its anatomic location. CT usually shows a contrast-enhancing mass that cannot always be distinguished from abscess or other lesions; in these cases, MRI may be more discriminating.

Systemic lymphomas in AIDS may involve the CNS. Kaposi’s sarcoma rarely involves the CNS.

Adequate primary prophylaxis for fungal, mycobacterial, and toxoplasmal infections is desirable but has not yet been developed. Secondary prophylaxis is indicated to prevent relapses of P. carinii pneumonia, cryptococcal infections, toxoplasmic encephalitis, herpes simplex, and thrush.

FUNGAL PNEUMONIA

PNEUMONIA CAUSED BY PNEUMOCYSTIS CARINII

Etiology

Pneumocystis carinii, recently suggested to be a fungus rather than a parasite, is usually dormant in the host lung, causes disease when defenses are compromised, and may be transmitted from patient to patient. Nearly all patients have immunologic deficiencies, the most common being defects in cell-mediated immunity as with hematologic malignancies, lymphoproliferative diseases, cancer chemotherapy, and AIDS. Among patients with HIV infection, about 60% have P. carinii pneumonia as the initial AIDS-defining diagnosis, and > 80% of AIDS patients have this infection at some time during their course. These patients account for a large proportion of pneumonias in patients requiring hospitalization in areas where AIDS is epidemic.

Symptoms and Signs

Most patients have a history of fever, dyspnea, and a dry, nonproductive cough that may evolve in a subacute fashion over several weeks or acutely over several days. The chest x-ray characteristically shows diffuse, bilateral, perihilar infiltrates, but 10 to 20% of patients have normal x-rays. Gallium scanning may be especially helpful in patients with typical symptoms and a negative chest x-ray. Arterial blood gases show hypoxemia, with a marked increase in the alveolar-arterial O2 gradient, and pulmonary function shows altered diffusing capacity. Patients with HIV become vulnerable to P. carinii pneumonia when the CD4 helper cell count is < 200/µL.
Patients with CD4+ lymphocyte counts < 200/µL should be encouraged to begin primary prophylaxis for P. carinii pneumonia with trimethoprim/sulfamethoxazole, dapsone, or aerosolized pentamidine. The relative efficacy of these regimens is under study. Because the sulfonamides and sulfones appear to provoke adverse effects (eg, fever, neutropenia, skin rashes) in these patients more frequently than in persons with normal immunity, many of these patients must rely on aerosolized pentamidine.

Marine Environmental Hazards
There is little information available concerning the effects of immersion, pressure and cold water on a person with HIV/AIDS. Any assumptions would be interpolative at best. There have been anecdotal reports of benefits from hyperbaric oxygenation. However, there is considerable information available about specific marine-associated infections that would be particularly hazardous to an immunosuppressed individual.
Infections caused by a mixture of bacteria, some requiring O2 and some not [aerobic and anaerobic] that cause necrotizing wounds can occur from injury, surgery or foreign bodies, and generally affect patients who have some underlying illness such as diabetes mellitus, poor circulation, or are immunosuppressed by medications or AIDS.

AUTHOR

Ernest S. Campbell, M.D., FACS

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