Endocarditis; HIV/AIDS

Question 1

Endocarditis diagnosis (fever + murmur)

Answer 1

1) Perform Blood cultures
2) If (+) perform TTEcho to look for valve vegetations
3) If TTE is (-); perform TEEcho
Diagnosis = 2 (+) cultures & (+) echo

Question 2

Endocarditis: Empiric Antibiotics

Answer 2

Draw blood culture & start empiric antibiotics
Abx: IV Vancomycin + Gentamicin in combination (to cover most common organisms: S. aureus, mRSA, viridans strept)
Treatment time: 4-6 weeks

Question 3

Endocarditis: When do you perform surgery (valve replacement)?

Answer 3

Anatomic defects including: (1)Valve rupture (2)Abscess (3)Prosthetic valves (4)Fungal endocarditis
(5)Embolic events once started on antibiotics (6)CHF

Question 4

Endocarditis Prophylaxis: Which cardiac defects require it?

Answer 4

(1) Prosthetic valves (2) Unrepaired cyanotic heart disease (3) Previous endocarditis (4) Transplant recipients who develop valve disease

Question 5

Endocarditis Prophylaxis: What procedures require it?

Answer 5

(1) Dental procedures w/ blood - amoxicillin or clindamycin

(2) Respiratory tract surgery (3)Surgery of infected skin.p

Question 6

HIV/AIDS - when to start therapy?

Answer 6

(1) CD4 count < 500 (normal 600-1,000)
(2) Symptomatic + CD4 count or viral load
(3) Pregnant women
(4) Needle-stick scenario, pt known to be HIV+

Question 7

HAART therapy:

Answer 7

(1) Tenofovir/Emtricitabine/Efavirenz
(2) Zidovudine/Lamivudine/Efavirenz
(3) Zidovudine/Lamivudine/Ritonavir

Question 8

HIV/AIDS diagnosis:

Answer 8

(1) Screening tool: ELISA (+) Western blot

(2) Confirm with: HIV RNA PCR to confirm high viral load or p24 antigen

Question 9

Prophylaxis:
Pneumocystis Jiroveci Pneumonia (PCP) (< 200 CD4)
Mycobacterium Avium-Intracellulare (MAI) (< 50 CD4)

Answer 9

PCP: TMP/SMX (rash: atovaquone or dapsone)
MAI: Azithromycin once a week orally

Question 10

Opportunistic Infection:

Pneumocystis Jiroveci Pneumonia (PCP) (< 200 CD4)

Answer 10

Best initial test: CXR (bilateral interstitial markings)
Most accurate: bronchoalveolar lavage
Tx: IV TMP-SMX (+) steroids if pO2 < 70 or A-a >35

Question 11

Opportunistic Infection: Toxoplasmosis

Answer 11

Best initial: head CT with contrast (ring enhancing)

Tx: Pyrimethamine & Sulfadiazine x 2 weeks; repeat CT; if lesions are smaller - confirmatory; if not - brain biopsy

Question 12

Opportunistic Infections: Cytomegalovirus (CMV) (<50)

Answer 12

Dx: Appearance on dilated opthalmologic examination
Tx: Ganciclovir or Foscarnet
Maintenance therapy: Oral Valaganciclovir lifelong (unless CD4 count goes up)

Question 13

Opportunistic Infections: Cryptococcus Neoformans (<50)

cutaneous cryptococcosis may be first sign to systemic disease

Answer 13

Best initial: LP with India Ink (increased lymphocytes on LP)
Most accurate: Cryptococcal Antigen test
Tx: Amphotericin, followed by Fluconazole.
- Fluconazole continued lifelong unless CD4 rises.

Question 14

Opportunistic Infection: Progressive Multifocal Encephalopathy (<50)

Answer 14

Best initial: Head CT/MRI (no ring-enhancement)
Tx: HAART; no specific therapy
(without HAART; most PML die within 3-6 months)

Question 15

Opportunistic Infections: Mycobacterium Avium-Intracellulare (MAI)

Answer 15

Dx: Liver biopsy > Bone marrow > Blood culture
Tx: Clarithromycin and Ethambutol

Question 16

Primary HIV Associated Thrombocytopenia

Answer 16

-effects 40% HIV(+) pts

Tx: Zidovudine

Question 17

HIV (+) Syphilis of unknown duration or acquired > 1YR ago

Answer 17

Best initial: LP/CSF examination (eval for neurosyphilis)
-RPR titers > 1:32 + CD4 < 350 = increased risk
Tx: Pen G IM weekly x 3 weeks

Question 18

Needle-Stick Injury (PEP)

Answer 18

Exposure to HIV+ blood or Unprotected sex

Tx: HAART x 1 month

Question 19

Pregnancy/Perinatal

Answer 19

Pt on therapy: continue therapy
Pt not on therapy: (1) CD4 < 500: Start HAART now
(2) CD4 > 500 + low viral load: Start HAART now

Question 20

HIV Lipodystrophy

Answer 20

Association with HAART: Insulin resistance/dyslipidemia
MC: Hypertriglyceridemia
1st line: statins; if >500 gemfibrizole

Question 21

S/Es: NRTIs “-vudine” (& abacavir, tenofovir, emtricitabine)
Zidovudine
Didanosine, Stavudine
Abacavir

Answer 21

NRTIs: Lactic acidosis
Zidovudine: Anemia
Didanosine, Stavudine: Pancreatitis, Neuropathy
Abacavir: Rash

Question 22

Side effects: Protease Inhibitors “-avir”

Idinavir

Answer 22

Protease Inhibitors: Hyperglycemia, Hyperlipidemia

Idinavir: Kidney stones

Question 23

Side effects: NNRTIs (“-ine” & “enz”)

Efavirenz, Nevirapine, Etravirine, Rilpivirine

Answer 23

NNRTIs: Drowsiness

Question 24

HAART naive pt beginning HAART - evaluation

Answer 24

Measure viral load @ 4, 8, 12 weeks
Remeasure every 6-8 weeks until undetectable
-Should decrease < 50 copies within 6 months

Question 25

HIV pts not on HAART or

HIV pts on HAART: monitor efficacy

Answer 25

Evaluate CD4 count & HIVl load Q 3-4 months

Question 26

Cutaneous Cryptococcosis

Answer 26

• Can be first sign of systemic Cryptococcus Neoformans
• Characteristic skin lesions: multiple, discrete, flesh/red colored papules varying in size with central umbilication usually on face/trunk
• Perform: Blood/CSF cultures, India Ink CSF, Cryptococcal antigen CSF/blood; Confirm with: biopsy of skin lesion