2: HIV-related infections Flashcards by Katie Hutchins

symptoms and signs of pneumocystis jiroveci

sx: gradual onset fever, dry cough, dyspnea
signs: fever, tachypnea, chest exam normal in 50%

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what will you see on imaging of pneumocystis jiroveci

CXR with diffuse bilateral interstitial infiltrates
-normal in 10-25% of cases

HRCT highly sensitive, helpful when CXR negative/ equivocal

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how do you diagnose pneumocystis jiroveci

immunofluorescent Ab staining
induced sputum
bronchoscopy/ BAL
LDH elevated

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how to patients initially respond to pneumocystis treatment?

patients typically worsen after 2-3d of therapy

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what is the role of corticosteroids in pneumocystis treatment?

give if PaO2

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antimicrobial options for pneumocystic treatment

IV TMP/SMX or pentamidine

- po TMP/SMX, TMP-dapsone, clindamycin-primaquine, atovaquone

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pneumocystic prophylaxis

when CD4

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when do you discontinue pneumocystic prophylaxis

increase in CD4>200 for >3mos

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cryptococcal meningitis sx and signs

subacute meningitis w/ fever
HA
malaise
occasional encephalopathic sx
often few sx even with very elevated ICP

-meningeal signs in minority

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CSF findings with cryptococcal meningitis

lymphocytic pleocytosis
mildly elevated protein
low-normal glucose
OP elevated to > 200mmH2O in up to 75% of cases

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cryptococcal meningitis diagnosis

serum and CSF crypto Ag very sensitive

- routine blood cultures + CSF fungal culture

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cryptococcal antifungal therapy

induction - amphoB + flucytosine for at least 2 wks
-if clinical progress maintenance: fluconazole 400 mg daily for 8 wks

secondary prophylaxis: fluconazole 200mg daily, can be stopped only if CD4>200 on HAART for >6 mos

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cryptococcal therapy: managing elevated ICP

if ICP>250 mmH2) and/or neuro signs: daily LP recommended to reduce ICP
consider CSF shunt if sx/signs of cerebral edema or daily LP no longer tolerated

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at what CD4 level do patients usually get CMV infection?

CD4

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end organ manifestations of CMV

retinitis most common
colitis
esophagitis
neuro disease - dementia, ventriculoencephalitis, ascending polyradiculomyelopathy
CMV viremia
CMV pneumonitis

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diagnosing latent TB in HIV

test all at HIV diagnosis, continue annual testing if high risk
PPD or IFNgamma release assay

how do you treat latent TB in HIV

INH daily or twice weekly for 9 mo
rifampin
rifabutin for 4 mos

how does TB present in severely immunocompromised, advanced HIV patients?

CXR:

less upper lobe cavitation
can see lower lobe
interstitial and miliary infiltrates
hilar/mediastinal adenopathy
occasionally normal

extrapulmonary manifestations more common with higher yield of AFB smear/culture of extrapulmonary specimens

histopathology with poorly formed or no granulomas

what is an independent predictor of mortality in HIV?

disseminated M. avium complex (MAC)

clinical presentation of MAC

fever
weight loss
sweats
diarrhea
lymphadenopathy
hepatosplenomegaly

abnormal lab values of MAC

anemia
elevated alkphos
CD4

how to diagnose MAC

blood culture (very sensitive)

- culture from other site (bone marrow)

what predicts increased risk of dissemination of MAC

respiratory colonization

disseminated MAC prevention

azithromycin 1200mg po/week
clarithromycin 500mg po BID
rifabutin 300mg po daily

rule out primary disease by clinical assessment before starting prophylaxis

when do you stop primary prophylaxis for MAC

when CD4>100 for more than 3mo

signs and symptoms of toxoplasmosis

sx: headache, fever, behavioral, lethargy, coord/gait, seizure, coma signs: hemi, ataxia, cranial nerves, aphasia, visual, extrapyramidal

what do you see in neuroimaging in toxoplasmosis

- focal lesions on CT/MRI (except rare diffuse encephalitis form) - multiple lesions in 2/3 of cases - ring enhancement ~90% - mass effect - edema preferential location: basal ganglia, grey-white jxn, white matter

what does CSF analysis look like in toxoplasmosis

- mild elevation of proteins - moderate mononucleared pleocytosis (60 cells/ml) - occasional decreased glucose

what is toxoplasmosis sometimes confused with?

primary CNS lymphoma | -diagnose for sure by seeing response on imaging to empiric treatment of toxopalsmosis (vs biopsy)

how often do you see primary CNS lymphoma in AIDS patients?

2-4%

what are CD4 counts like in AIDS patients with primary CNS lymphoma?

signs and sx of primary CNA lymphoma

- confusion - lethargy - memory loss - hemiparesis or aphasia - seizures - cranial nerve palsy - headache (uncommon) NO FEVER unless concomitant infection

what do you see on neuroimaging of primary CNS lymphoma

CT/MRI: - multiple lesions as frequent as single lesion - nodular or patchy enhancement - subependymal enhancement (more specific) - variable mass effect - localization to cortex, deep structures - thallium-201 SPECT shows increased metabolic activity

what will CSF show in primary CNS lymphoma

-mild mononucleared pleocytosis (

how does one get PML (progressive multifocal luekoencephalopathy)

asymptomatic JC virus infection in childhood - latency in kidneys, lymphoid organs, bone marrow, brain

percent of AIDS patients with PML before and on cART

before: 5% on: 0.06%

diagnosis of PML

brain biopsy or CSF PCR detection of JCV DNA

cure for PML

none - ~50% survival at one year in HIV+ patients, no effective treatment