HIV Flashcards
HIV CD4 350-500 cells - clinical stage
Asymptomatic
Lymphadenopathy
Recurrent respiratory tract infections
Herpes zoster
Recurrent oral ulcers
Eosinophilic folliculitis
HIV CD4 200-350 cells - clinical stage
Persistent oral candidiasis
Oral hairy leukoplakia
Pulmonary TB
Severe bacterial infections
Ulcerative stomatitis/gingivitis/periordontitis
HIV CD4 <200 clinical stage
HIV wasting
PCP
Oesophageal candidiasis
Extrapulmonary TB
Kaposi’s sarcoma
CNS toxoplasmosis
Extrapulmonary cryptococcosis
Disseminated NTB mycobacterial infection
Chronic isosporidiosis
Chronic cryptosporidiosis
Disseminated mycosis
Lymphoma
Progressive multifocal leukoencephalopathy
Cerebral toxoplasmosis - summary
Toxoplasma gondii
PCR on CSF
Serology
Neurimaging (multiple ring enhancing lesions)
Co-trimoxazole 4 weeks + ART
TB meningitis - summary
CSF: Lymphocytic, low glucose, high protein
RHZE 9-12 months
Steroids
Cryptococcal meningitis
Headache, meningism, focal neurology
CSF: CrAg and culture
Treatment:
Induction: flucytosine + fluconazole + single dose amphotericin B
Fluconazole consolidation
Molluscum contagiosum in HIV
Poxvirus
Can become widespread (IRIS)
Differentials: cryptococcus, histoplasmosis, talaromycosis
Hepes zoster in HIV
Reactivation of VZV –> painful vesicles that do not cross the midline
Valaciclovir/IV aciclovir
Papular pruritic eruption in HIV
Eosinophilic foliculitis - cause unknown - symmetrical itchy papulaes on the face/trunk/extremeties
Chronic diarrhoea in HIV - causes
HIV itself
Medication
Infections
- Cyptosporidium - ART
- CMV colitis
- TB
- Schistosomiasis
- Amoebiasis
- NTM
Oesophageal lesions in HIV - causes
Oesophageal candidiasis
CMV
Malignancy
Oral hairy leukoplakia
EBV related, no specific treatment
PCP in HIV - diagnostics and treatment
PCR +/- microscopy on BAL/sputum
BD glucan
Treatment: co-trimoxazole
What is kaposi sarcoma?
Vascular tumour with red/brown bigmentation secondary to infection with HHV-8
Commonly affects skin but can affect the palate, lungs, GI tract and lymph nodes
How do you make a diagnosis of HIV?
2 serological assays p24 AG +/- AB
Immunotyping for HIV1/2
Viral load (quantitative PCR)
Whats the first line treatment for HIV (as per WHO guidelines, no Hep B)
Tenofovir disoproxil fumarate (TDF) + Lamivudine (3TC) + Dolutegravir
When to start treatment for HIV?
ASAP EXCEPT:
Cryptococcal meningitis
TB meningitis
What kind of virus is HIV?
Retrovirus - i.e. inserts a DNA copy of its genome into the host cell to replicate
What are some things to check before initiating on ART?
HTN
CVD
DM
Pregnancy
TB
LFTs
Proteinuria
Hepatitis B surface antigen
NRTI
Nucleoside reverse transciptase inhibitors
Block reverse transcriptase enzyme, preventing HIV RNA from converting to DNA
e.g. tenofovir, zidovudine, lamuvidine
SE: severe renal impairment, hypersensitivity, liver disease
Avoid TDF in osteoporosis
NNRTI
Non nucleoside reverse transciptase inhibitors
Bind directly to the reverse transciptase enzyme to prevent HIV RNA converting to DNA
e.g. Efavirenz
Rash, hepatotoxicity, CNS effects (psychological), high rates of resistance
Protease inhibitors in HIV
Atanivir, ritonavir
Severe liver disease
Hyperlipidaemia
Hyperglycaemia
Avoid in CVD
Advise giving in renal disease
Integrase inhibitors in HIV
Dolutegravir
Weight gain, hypersensitivity, hepatotoxicity
Harmlessly can increase creatinine - usually plateaus at week 4 and should not be progressive
HIV associated nephropathy (HIVAN)
Nephrotic syndrome
Dx Biopsy required - Collapsing FSGS, tubular microcystic dilation, and interstitial inflammation
Enlarged bright kidneys on US
Limited to black patients APOL-1 gene
Progressive multifocal leukenencephalopathy (PML) in HIV
PML - reactivation of JC virus (affects oligodendrocytes)
Symptoms - muscle weakness, sensory deficits, hemianopia, gait disturbance
Multiple lesions are hypodense with no surrounding changes like odoema
HIV patient presenting with headache, confusion and drowsiness. Her CT shows multiple ring enhancing lesions with some surrounding odoema
Toxplasmosis
Mx: sulfadiazine and pyrimethamine (+folinic acid)
HIV patient presenting with weight loss and a single homogenous enhancing lesion on CT brain
Lymphoma
Patient with HIV presenting with headache, fever, malaise and seizures. LP - lymphocytosis and high opening pressure. CT shows meningeal enhancement and cerebral odoema
TB
Cryptococcal meningitis
HIV patient with subacute speech and motor impairment with hemianopia. CT shows multiple non-enhancing lesions.
PML
Approach to lymphadenopathy in HIV
Any CD4 count
TB
Syphilis
Lymphoma
KS
NTM
CD4 <100
Dimorphic fungal infections
Nocardia
Cryptococcus
Which ART is it normal to have a raised bilirubin?
Atazanavir (ATZ)
Which ART class is most linked with resistance and should be switched if there is a rebound jump in viral load?
NNRTI
Preferred option for PEP in adults
Tenofovir + lamuvidine + dolutegravir
Preferred option for PEP in children
Zidovudine + lamuvidine + dolutegravir
Management of HIV vertical transmission
For infants - dual prophylaxis with daily Zidovudine and Nevirapine for the first six weeks of life (or 12 weeks if considered high risk)
What monitoring is required for ART monitoring?
CD4 count can be stopped once established on ART
HIV viral load preferable for monitoring
LFTs
Renal function
When should NNRTIs be avoided?
Previous resistance
Population resistance is >10%
Treatment for cryptococcal meningitis in HIV
1 week induction
Amphotericin B + flucystosine (or fluconazole + flucytosine)
followed by fluconazole 8 weeks
Treatment of disseminated histoplasmosis in HIV
Check histoplasma antigens
2 weeks amphotericin B (renal function)
12 months itraconazole
When to give prophylactic co-trimoxazole?
CD4 <350
How do you do a TB screen in patients living with HIV?
Four-symptom screen: current cough, fever,
weight loss or night sweats
Consider also CXR + PCR if symptomatic or in endemic region
Treatment for latent TB (including in HIV)
- 6-9 months isoniazid
- 3 months of isoniazid + rifapentine
- 3 months of isoniazid + rifampicin
