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ICM > 2: HIV-related infections > Flashcards

2: HIV-related infections Flashcards

1
Q

symptoms and signs of pneumocystis jiroveci

A

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

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2
Q

what will you see on imaging of pneumocystis jiroveci

A

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

HRCT highly sensitive, helpful when CXR negative/ equivocal

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3
Q

how do you diagnose pneumocystis jiroveci

A
  • immunofluorescent Ab staining
  • induced sputum
  • bronchoscopy/ BAL
  • LDH elevated
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4
Q

how to patients initially respond to pneumocystis treatment?

A

patients typically worsen after 2-3d of therapy

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5
Q

what is the role of corticosteroids in pneumocystis treatment?

A

give if PaO2

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6
Q

antimicrobial options for pneumocystic treatment

A
  • IV TMP/SMX or pentamidine

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

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7
Q

pneumocystic prophylaxis

A

when CD4

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8
Q

when do you discontinue pneumocystic prophylaxis

A

increase in CD4>200 for >3mos

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9
Q

cryptococcal meningitis sx and signs

A
  • 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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10
Q

CSF findings with cryptococcal meningitis

A
  • lymphocytic pleocytosis
  • mildly elevated protein
  • low-normal glucose
  • OP elevated to > 200mmH2O in up to 75% of cases
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11
Q

cryptococcal meningitis diagnosis

A
  • serum and CSF crypto Ag very sensitive

- routine blood cultures + CSF fungal culture

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12
Q

cryptococcal antifungal therapy

A

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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13
Q

cryptococcal therapy: managing elevated ICP

A
  • 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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14
Q

at what CD4 level do patients usually get CMV infection?

A

CD4

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15
Q

end organ manifestations of CMV

A
  • retinitis most common
  • colitis
  • esophagitis
  • neuro disease - dementia, ventriculoencephalitis, ascending polyradiculomyelopathy
  • CMV viremia
  • CMV pneumonitis
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16
Q

diagnosing latent TB in HIV

A
  • test all at HIV diagnosis, continue annual testing if high risk
  • PPD or IFNgamma release assay
17
Q

how do you treat latent TB in HIV

A

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

18
Q

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

A

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

19
Q

what is an independent predictor of mortality in HIV?

A

disseminated M. avium complex (MAC)

20
Q

clinical presentation of MAC

A
  • fever
  • weight loss
  • sweats
  • diarrhea
  • lymphadenopathy
  • hepatosplenomegaly
21
Q

abnormal lab values of MAC

A
  • anemia
  • elevated alkphos
  • CD4
22
Q

how to diagnose MAC

A
  • blood culture (very sensitive)

- culture from other site (bone marrow)

23
Q

what predicts increased risk of dissemination of MAC

A

respiratory colonization

24
Q

disseminated MAC prevention

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

rule out primary disease by clinical assessment before starting prophylaxis

25
Q

when do you stop primary prophylaxis for MAC

A

when CD4>100 for more than 3mo

26
Q

signs and symptoms of toxoplasmosis

A

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

27
Q

what do you see in neuroimaging in toxoplasmosis

A
  • 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

28
Q

what does CSF analysis look like in toxoplasmosis

A
  • mild elevation of proteins
  • moderate mononucleared pleocytosis (60 cells/ml)
  • occasional decreased glucose
29
Q

what is toxoplasmosis sometimes confused with?

A

primary CNS lymphoma

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

30
Q

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

A

2-4%

31
Q

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

A
32
Q

signs and sx of primary CNA lymphoma

A
  • confusion
  • lethargy
  • memory loss
  • hemiparesis or aphasia
  • seizures
  • cranial nerve palsy
  • headache (uncommon)

NO FEVER unless concomitant infection

33
Q

what do you see on neuroimaging of primary CNS lymphoma

A

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
34
Q

what will CSF show in primary CNS lymphoma

A

-mild mononucleared pleocytosis (

35
Q

how does one get PML (progressive multifocal luekoencephalopathy)

A

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

36
Q

percent of AIDS patients with PML before and on cART

A

before: 5%
on: 0.06%

37
Q

diagnosis of PML

A

brain biopsy or CSF PCR detection of JCV DNA

38
Q

cure for PML

A

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

ICM (26 decks)

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