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Term 5: Infectious Disease > 6/2- HIV, Opportunistic Infections > Flashcards

6/2- HIV, Opportunistic Infections Flashcards

1
Q

__% of new diagnosis have CD4 less than ___

A

30% of new diagnosis have CD4 < 200

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2
Q

Labs for new HIV pt?

A

- CD4 cell count, HIV 1 viral load, HIV genotype

  • CBC, chemistries, lipid panel
  • Viral hepatitis serologies (A, B, C)
  • STD screening: RPR for syphilis, test for chlamydia and gonorrhea
  • Screen for TB: PPD or blood IGR tests (quantiferon)
  • Other: Toxoplasma antibody
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3
Q

Several types of non-AIDS defining cancer are more common in HIV and should be considered in routine clinic visits. What are they?

A
  • Anal
  • Hodgkin
  • Lymphoma
  • Liver
  • Lung
  • Melanoma
  • Oropharyngeal
  • Leukemia
  • Colorectal
  • Renal
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4
Q

Opportunistic Diseases (chart)

A
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5
Q

CD4 less than __ is threshold for Pneumocystis pneumonia?

A

CD4 less than 200 is threshold for Pneumocystis pneumonia

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6
Q

CD4 less than __ is threshold for Histplasmosis?

A

CD4 less than 100 is threshold for Histplasmosis

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7
Q

Relevant CD4 thresholds?

A
  • > 500: normal
  • 350-500: impaired

- less than 200 -> Pneumocystis, thrush

- less than 100 -> risk for everything else

At same CD4 cell count, treatment and viral suppression lowers risk for OI

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8
Q

What is this?

Symptoms?

What’s the CD4 count?

A

Thrush- oral candidiasis

  • White, curd-like plaques that can be scraped off leaving a raw surface
  • If you see this, you can basically SAY that pt has HIV with CD4 near/less than 200
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9
Q

What is this? Symptoms?

A

Oral Hairy Leukoplakia

  • Verrucouous white excrescences on the lateral margins of the tongue; not readily scraped off
  • Frequently seen in HIV pts, often prior to symptomatic HIV dz
  • Thought to be due to Ebstein-Barr virus
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10
Q

Other oral, what other forms of candidiasis are there?

Characteristics?

Treatment?

A

Esophageal

  • Substernal chest pain, dysphagia
  • Diff Dx: CMV, HSV, PUD, other
  • Persistent dysphagia after 3-5 days of antifungals; proceed with endoscopy

Vaginal candidiasis

  • Can be unusually persistent

Treatment = fluconazole

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11
Q

Case 1

  • 45 yo woman, HIV positive, CD4 190, not on treatment
  • Fever of 102 for 3 days, with cough productive of green phlegm, pleuritic chest pain, mild SOB
  • Chest x-ray

What is the cause of her illness?

A. Influenza virus

B. Pneumocystis jirovecii

C. Histpolasma capsulatum

D. Streptococcus pneumoniae

E. Mycobacterium tuberculosis

A

Case 1

  • 45 yo woman, HIV positive, CD4 190, not on treatment
  • Fever of 102 for 3 days, with cough productive of green phlegm, pleuritic chest pain, mild SOB
  • Chest x-ray

What is the cause of her illness?

A. Influenza virus

B. Pneumocystis jirovecii

C. Histpolasma capsulatum

D. Streptococcus pneumoniae ?

E. Mycobacterium tuberculosis

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12
Q

What is the most common pathogen involved in bacterial pneumonia in HIV?

A

S. pneumoniae

HIV confers a 100-fold greater risk of invasive pneumococcal dz

Diagnose with:

  • Gm stain, blood cultures (bacteremia in 50%)
  • Pneumococcal urine antigen
  • Legionella ag.

Prevention:

  • Antiretroviral treatment
  • Immunization w/ pneumococcal vaccine
  • Influenza vaccination annuallyh
  • Smoking cessation
  • ABx given for PCP/MAC prophylaxis
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13
Q

Case 2:

  • Pt with HIV, fever, cough, SOB for 2-3 wks
  • Diffuse, bilateral pulmonary infiltrates and hypoxia

What is this typical presentation?

A

PCP- Pneumocystis pneumonia

  • Human disease caused by Pneumocystis jirovecii (fungus)
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14
Q

Classic presentation of PCP

A
  • Insidious onset of fevers, cough, dyspnea (2-3 weeks)
  • Impaired oxygenation- check pulse ox on exertion if normal at rest (exercise-induced desaturation)
  • Elevated LDH (moderate)
  • Bilateral interstitial infiltrates in 80%
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15
Q

Diagnosis of PCP?

A
  • Induced sputum
  • Bronchoscopy for BAL
  • Immunofluorescence stains increase sensitivity
  • PCR tests available
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16
Q

What is this?

A

Silver stain of BAL of Pneumocystis

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17
Q

Treatment and Prevention of PCP in HIV?

A

Drug of choice = trimethoprim-sulfamethoxazole (TMP/SMX)

Adjunctive treatment with corticosteroids for moderate/severe dz (defined by level of hypoxia)

Will initially worsen but then improve on treatment

Prevention: at CD4 < 200 until it gets higher; same for 2ndary prevention

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18
Q

Case 3

  • 56 yo HIV infected man, not on Rx, homeless, admitted with a 3 mo Hx of weight loss (30 pounds), fever, progressive cough, hemoptysis, pleuritic chest pain, SOB
  • PE: febrile, tachypneic, decreased BS left upper lung
  • Labs: CBC 10,000. CD4 cell count 250
  • CXR showed a small infiltrate in RUL, extensive opacificication in LUL as well as some infiltrate in the superior segment of the lingula

What is this?

A

M. tuberculosis

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19
Q

At what broad CD4 levels do HIV pts get M. tuberculosis? Symptoms?

A

Relatively high CD4 cell count- classic presentation of pulmonary TB:

  • fever
  • night sweats
  • weight loss
  • hemoptysis
  • cavitary upper lobe infiltrates

As the T cell drop, less typical presentations and extrapulmonary TB become more common Different radiographic patterns

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20
Q

What is the recommended mode of diagnosis for M. tuberculosis?

A

PCR (should also culture sputum?)

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21
Q

Prevention for M. tuberculosis?

A

ALL persons with HIV should be tested for latent TB

  • PPD test >= 5mm is positive
  • IGRA blood tests (Quantiferon, T spot)

If any positive PPD or IGRA, rule out active dz

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22
Q

Treatment for M. tuberculosis in HIV pts if no active dz? Active dz?

A

If no active dz:

- INH for 9 mo

If active dz:

  • TB treatment with 4 drugs for 2 mo/2 drugs rest
  • Directly observed therapy (DOT)

HIV-infected close contacts of proven TB should be treated regardless of PPD

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23
Q

Case 4

  • 56 yo veteran, smoker
  • Brought to ER with AMS
  • PE: Febrile, somnolent, confused, left arm paresis
  • Labs: CBC 3500, Hb 11
  • CXR RUL nodule, no infiltrates

What is this?

A

Toxoplasmosis

Wouldn’t think so unless knew immunocompromised or HIV, but in this case they were

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24
Q

What is this?

A

Enhanced T1 MRI of toxoplasmosis in AIDS pt showing multiple ring and nodular enhancing lesions

(On CT too, see multiple ring-enhancing hypodense lesions with surrounding edema)

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25
Q

Characteristics of long term toxoplasmosis?

A
  • Complete blood count shows anemia, leukopenia, or leukocytosis in congenital toxo
  • In most AIDS pts, dz is limited to the brain
  • CSF is abnormal in most AIDS pts
  • Lymphocytic pleocytosis is usually mild but may be as high as several thousand cells/mm3
  • Protein level is increased and glucose level is usually nl or rarely mildly reduced
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26
Q

At what CD4 levels do you see reactivation dz of Toxoplasma?

A

CD4 < 100 (in toxoplama Ab positive persons)

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27
Q

Presentation of toxoplasma encephalitis in HIV?

A
  • Fever
  • Focal neurologic symptoms
  • Altered mental status
  • Seizures
28
Q

Treatment for toxoplasma encephalitis?

A

- Pyrimethamine + sulfadiazine

Should see clinical and radiologic improvement within 2 weeks; if no initial improvement, need to consider dx and pursue brain biopsy

29
Q

Diagnosis of Toxoplasma encephalitis?

A
  • Imaging with contrast: brain ring-enhancing lesions
  • LP: CSF toxoplasma PCR

(- Serology: serum IgG positive in > 90% of cases, IgG in CSF positive in 50% but specific)

30
Q

What is this?

A

Ring-enhancing lesions: CNS Lymphoma

31
Q

What is the most common cause of meningitis in HIV?

A

Cryptococcus neoformans meningitis

32
Q

Symptoms of cryptococcal meningitis?

A
  • Headaches
  • Fever for 1-3 wks
  • Stiff neck not a consistent finding!
33
Q

Diagnosis of Cryptococcus?

A
  • Cryptoccocal antigen in serum
  • LP and CSF eval: crypto antien, Gm stain
  • Opening pressure: prognostic and therapeutic value
34
Q

Treatment for cryptococcal meningitis? Timeline?

A

Amphotericin B for 2 weeks

Followed by Fluconazole Maintenance therapy until CD4 > 100 with ART

35
Q

What is another common cause of meningitis in HIV pts (highly prevalent in endemic areas like W of San Antonio)?

A

Coccidioides immitis

36
Q

What is this? When is it most commonly seen?

A

India Ink Preparation of Cryptococcus neoformans

  • Can see the prominent capsule
  • India ink test is + in 50-60% of the time, more frequently in pts with AIDS
37
Q

What causes PML (Progressive Multifocal Leukoencephalopathy)?

A

JC viral infection

38
Q

At what CD4 count to HIV pts typically present with PML (progressive multifocal leukoencephalopathy)?

A

CD4 < 100 (low CD4)

39
Q

Presentation of PML?

A
  • Progressive neurologic impairment
  • Fever
  • Headaches do not occur
40
Q

MRI shows what in PML?

A

Typical non-enhancing lesions

  • Increased signal intensity in L frontal lobe and corona radiata with extension across midline in mpt wit hprogressive PML
  • Subcortical U fibers are involved
41
Q

Diagnoses PML how?

A

CSF PCR or biopsy

  • No specific finding in CSF (normal)
  • EEG changes are nonspecific
  • Serologic testing not helpful (since most adults already have Ab to JC virus)
42
Q

Treatment for PML?

A

ART

43
Q

CNS disease and HIV: Summary

Space-occupying lesions:

-

-

Sub-acute meningitis:

-

-

Enephalopathy (white matter dz)

-

-

-

A

CNS disease and HIV: Summary

Space-occupying lesions:

- Toxoplasmosis

- Lymphoma

Sub-acute meningitis:

- Cryptococcus neoformans

- TB

Enephalopathy (white matter dz)

- PML

- CMV encephalitis

- HIV encephalitis

44
Q

Disseminated dz in HIV typically presents how?

A

Diseases presenting with a sub-acute syndrome of fever, pancytopenia, +/- lymphadenpathy, +/- enlarged liver and/or spleen

45
Q

Typical disseminated dz causes in HIV pts?

  • Fungal:
  • Mycobacterial:
  • Bacterial:
  • Neoplastic:
A

Typical disseminated dz causes in HIV pts:

  • Fungal: histplasmosis
  • Mycobacterial: TB, MAC
  • Bacterial: bartonella (CSD)
  • Neoplastic: lymphoma
46
Q

At what CD4 levels does histoplasmosis typically cause progressive disseminated dz?

A

CD4 < 100

47
Q

Presentation of disseminated histoplasmosis?

A

(Endemic in Ohio and Mississippi river valleys, including Houston)

  • Manifestations 2ndary to involvement of reticulo-endothelial system
  • Can also present as localized dz
  • Mucosal ulcerations (mouth, GIT) should suggest diagnosis
48
Q

Question:

Which of the following could be used to diagnose Histoplasmosis?

A. Blood cultures for fungus

B. Urine for histoplasma antigen

C. Bone marrow for pathology and culture

D. Lymph node for pathology and culture

E. All of the above

A

Question:

Which of the following could be used to diagnose Histoplasmosis?

A. Blood cultures for fungus

B. Urine for histoplasma antigen

C. Bone marrow for pathology and culture

D. Lymph node for pathology and culture

E. All of the above

49
Q

What is this?

A

Histoplasma capsulatum inside a leukocyte

50
Q

At what CD4 levels is M. avium complex (MAC) seen in HIV pts?

A

CD4 < 50

51
Q

Symptoms of disseminated MAC?

A
  • Fever, night sweats, weight loss, diarrhea, anorexia
  • Reticuloendothelial involvement (LAN, HSM, pancytopenia)
52
Q

Treatment of MAC?

A

Clarithromycin (azithro), ethambutol, rifabutin

53
Q

Prevention of MAC?

A

Weekly azithromycin when CD4 < 50

54
Q

What is the MCC of diarrhea in HIV pts?

A

C. difficile

55
Q

List of MCCs of diarrhea in HIV pts

Bacterial:

Protozoa:

Viral:

A

Bacterial:

    • C. difficile (#1)*
  • Shigella
  • Campylobacter
  • Salmonella (typhi, non-typhi)

Protozoa:

  • E. histolytica
  • G. lambia
  • Cryptosporidiosis
  • Isospora
  • Microsporidia
  • Cyclospora

Viral:

  • CMV
  • HIV itself
56
Q

Treatment of diarrhea in HIV pt?

A

Immune recovery (ART)

57
Q

At what CD4 levels do you see disseminated CMV in HIV pts?

A

CD4 < 50

58
Q

Infections that manifest with CMV when CD4 < 50?

A
  • CMV retinitis (floaters)
  • CMV esophagitis (dysphagia)
  • CMV colitis (diarrhea)
  • CMV encephalitis
  • Polyradiculitis
  • CMV pneumonitis
59
Q

Diagnosis of CMV?

A

Seropositivity in > 90% of persons with HIV

  • Diagnosis depends on organ involved, PCR
60
Q

Treatment of CMV?

A
  • Ganciclovir (IV) (bone marrow suppression)
  • Valganciclovir (oral)
  • Foscarnet as an alternative (renal failure risk)
  • Also HAART for immune recovery
61
Q

What is this?

A

Kaposi’s sarcoma (HHV 8)- oncogenic virus

62
Q

EBV causes what cancers commonly? Risks in HIV?

A

Primary CNS lymphoma

  • Essentially all have latent EBV DNA
  • Incidence dramatically increased in end-stage AIDS
  • PCR of CSF can be useful for diagnosis

Systemic lymphoma

  • NHL and Hodgkin’s dz increased in HIV
  • In many cases, the tumor contains EBV DNA
  • Treatment involves chemotherapy + HAART
63
Q

Symptoms of Human Papilloma Virus (HPV)?

A

- Anogenital warts (condyloma acuminata)

- Oncogenic strains common in persons with HIV

— inavasive cervical cancer (AIDS-defining)

— Anal carcinoma (men and women)

64
Q

Management of pts diagnosed with OI?

A
  • Treatment for specified time for OI
  • Antiretroviral treatment: start if at all possible within 2 wks
  • Close follow-up for devo of IRIS
  • Suppressive therapy after completion of active phase of treatment (can be discontinued if CD4 count increases over OI specific thresholds)
65
Q

What is IRIS? Manifestations?

A

Immune Reconstitution Inflammatory Syndrome

  • Paradoxical worsening as a result of immune recovery after starting ART
  • immune system wakes up and reacts to antigens to which it was not properly reacting before
  • Significant inflammation (overreaction to lots of antigen) against known pathogen or unmasking of previously unknown pathogens

Manifestations depend on the pathogen and dz process

66
Q

Summary: pts that present with OI - Treatment?

A
  • Diagnose and treat OI
  • Start ART if at all possible within 2 wks
  • Counsel and watch for IRIS-
  • If IRIS, continue ART and treat symptoms and/or inflammation
  • Continue secondary prevention until CD4 over OI pertinent threshold
67
Q

Case

  • 40 yo man diagnosed with HIV
  • CD4 is 200 and viral load is 55,000 RNA copies/mL; PPD is positive
  • What would be the intervention with the most impact?

A. Start PCP prophylaxis

B. Start antiretroviral treatment

C. Start treatment for latent TB

D. Administer pneumoccocal vaccine

E. Administer the hep A and B vaccines

A

Case

  • 40 yo man diagnosed with HIV
  • CD4 is 200 and viral load is 55,000 RNA copies/mL; PPD is positive
  • What would be the intervention with the most impact?

A. Start PCP prophylaxis

B. Start antiretroviral treatment ??

C. Start treatment for latent TB

D. Administer pneumoccocal vaccine

E. Administer the hep A and B vaccines

Term 5: Infectious Disease (18 decks)

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