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Multisystem 1st Half > common opportunistic infections with HIV/immunosuppression > Flashcards

common opportunistic infections with HIV/immunosuppression Flashcards

1
Q

9 common OIs with immunosuppression

A

esophageal candidiasis PCP MAC CMV KS AIDs dementia TB cryptococcosis

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2
Q

IRIS

A

immune reconstitution inflammatory syndrome • Reversal of HIV-related immune system decline with ART —-increases functional CD4 cells which causes a brisk immune response against pathogens (HIV, CMV, TB) • Restoring CD4 immunity  sometimes causes hypersensitivity reaction to any existing antigen in the body! • Patients may develop OIs while immune system is recovering if antigen is present o Most commonly seen in patients with low CD4 within first few weeks of starting ART • Paradoxical response!! o Need to continue ART even though hard to distinguish from clinical failure; may be self-limited but also may need to be treated with antibiotic and steroids

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3
Q

PCP

A

pneumocystis jirovecii pneumonia pneumocystis jirovecii has tropism for the lungs o Nonspecific symptoms like fever, nonproductive cough, substernal chest tightness, SOB; ongoing and subtle for months o Fever and tachypnea o CXR – ground glass appearance; diffuse interstitial infiltrates; aerosolized pentamidine-upper lobe infiltrates o Labs – anemia, nonspecific increase in LDH

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4
Q

risk for PCP is

A

long term steroids and immunosuppression

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5
Q

what is an accurate indicator of susceptibility to PCP?

A

CD4 count

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6
Q

how to diagnose PCP

A

o Cysts or trophozoites in tissue or body fluid o Induced sputum via neb saline o BAL – bronchoalveolar lavage; very sensitive! (100%) o PCR – detect in oral washes; possible asymptomatic colonization

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7
Q

best treatment for PCP?

A

either bactram or TMP/SMX

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8
Q

other treatments (2nd line) for PCP?

A

-TMP/Dapsone –but dont use with GI issues -pentamidine - more toxic overall than TMP/SMX -atovaquone - but less effective than TMP/SMX

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9
Q

what to include in PCP treatment?

A

prednisone steroids if pO2 is less than 70 or Aa gradient >35

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10
Q

PCP prophylaxis

A

aerosolized pentamidine TMP/SMX or dapsone

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11
Q

salmonella sources

A

reptiles raw eggs/hollandaise/caesar dressing

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12
Q

bird poop can cause

A

cryptococcus histoplasmosis mac

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13
Q

toxoplasmosis -org? -susceptibility? -presentation?

A

Due to Toxoplasma gondii; Common cause of CNS space occupying lesion in AIDs patient o 3 forms: proliferative (tachyzoites), tissue cyst, and oocyst o Reactivation disease latent tissue cysts – acquired ingestion of raw meat (lamb) or cat feces • Susceptible when CD4 multiple ring enhancing lesion in basal ganglion o Serology –> IgG toxoplasma antibody = toxo

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14
Q
A

toxoplasmosis

toxoplasma gondii

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15
Q

what stain is best to directly visualize t gondii?

A

peroxidase-antiperoxidase stain

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16
Q

treatment for toxoplasmosis

A
  • Pyrimethamine/sulfadiazine – 1st line; combo is synergistic
    • Sequential blocks of folic acid metabolism that is required for T gondii proliferation
    • Cysts remain viable and account for relapses
    • Add leucovorin to rescue other cells
  • Use steroids if cerebral edema is present
17
Q

toxoplasmosis prophylaxis?

A

tmp/smx

18
Q

tmp/smx stands for

A

Trimethoprim/sulfamethoxazole (TMP/SMX)

19
Q

cryptococcal meningitis

A
  • Caused by fungus C. neoformas; inhalation –> disseminates to CNS and other organs
  • In patients with CD4<100
  • Symptoms = days to weeks; headache, altered MS, meningismus, seizures, CN palsies; fever
  • **all HIV patients with fever should have a serum cryptococcal antigen; less likely disease if on an azole
20
Q

diagnosis of cryptococcal meningitis

A
  • CRAG (cryptococcal antigen test) – latex agglutination test of cryptococcal polysaccharide antigen of capsule; very sensitive and rapid; uses blood, csf, or other body fluid
  • Blood culture – can grow c neoformans; if found extraneurally –> poor px
  • Csf exam = crypto antigen
  • CT scan – normal
  • MRI with GAD = basilar meningitis with meningeal enhancement
21
Q

treatment for cryptococcus meningitis

A
    • AmphoB with 5FC (flucytosine) for first 2 weeks
      • After no more headache or fever –> switch to fluconazole (better tolerated and less toxicity)
      • Fluconazole can be first choice if MS is normal, CSF count >20, CSF crypto antigen <1:1024
22
Q

CMV chorioretinitis

A
  • CD4 cell count is main risk factor
  • Begins unilaterally –> progresses to bilateral involvement secondary to viremia
  • Symptoms: decreased visual acuity, floaters, visual field loss
  • Exam = yellow/white granular areas with perivascular exudate and hemorrhages (cottage cheese and ketchup); begins in periphery of fundus and if untreated progresses to macula and optic disc
23
Q

CMV chorioretinitis diagnosis

A
  • Visual – dilated fundus exam
  • CMV antibody indicates past exposure
  • CMV blood culture – viremia common
  • Routine dilated opth exams if CD4<50
24
Q

IRU

A
  • (immune recovery uveitis) – reconstitution syndrome
    • Vitreous inflammation, macular edema, and inactive or regressed CMV; only occurs in patient with immune recovery
    • Persistent antigenic load in the eye
25
Q

treatment of cmv chorioretinitis

A
  • Gangiciclovir, foscarnet, or valganciclovir
  • CMV systemic treatment =cidofovir (broad spectrum; long intracellular half life)
  • CMV primary prophylaxis is not standard of care
26
Q

MAC

A

(mycobacterium avium complex)

  • Intracellular org; found in fresh water, sea water, soil, animals, dairy products
  • Enter via GI or respiratory
    • After ingestion –> spreads locally in lymphatics and then disseminates hematogenously
    • Mycobacteria taken up by mononuclear phagocytic cells and reticuloendothelial cells: spleen, liver, bone marrow
  • Pulmonary/COPD; cervical adenitis in kids
  • Patients with CD4<100; marker of immune system failure
  • Presentations
    • Fever, night sweats, diarrhea, weight loss, anemia
    • Reticuloendothelial disease = intraabdominal lymphadenopathy, hepatosplenomegaly
27
Q

diagnosis of mac

A
  • Isolator tube (AFB blood culture) – lytic agent/anticoagulant; promotes lysis of WBC to increase yield of culture since MAC is intracellular
  • Blood or stool culture – dissemination
28
Q

treatment of MAC

A
  • Use MULti-TX – atleast 2 drugs for life or until ART immune recovery
    • 1st = clarithromycin or azithromycin
    • 2nd = ethambutol
    • And one of more of: raifabutin, rifampin, ciprofloxacin, amikacin
  • Prophylaxis = macrolides (clarithromycin or azithromycin)

Multisystem 1st Half (23 decks)

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