HIV

Question 1

HIV CD4 350-500 cells - clinical stage

Answer 1

Asymptomatic
Lymphadenopathy

Recurrent respiratory tract infections
Herpes zoster
Recurrent oral ulcers
Eosinophilic folliculitis

Question 2

HIV CD4 200-350 cells - clinical stage

Answer 2

Persistent oral candidiasis
Oral hairy leukoplakia
Pulmonary TB
Severe bacterial infections
Ulcerative stomatitis/gingivitis/periordontitis

Question 3

HIV CD4 <200 clinical stage

Answer 3

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

Question 4

Cerebral toxoplasmosis - summary

Answer 4

Toxoplasma gondii

PCR on CSF
Serology
Neurimaging (multiple lesions)

Co-trimoxazole 4 weeks + ART

Question 5

TB meningitis - summary

Answer 5

CSF: Lymphocytic, low glucose, high protein
RHZE 9-12 months
Steroids

Question 6

Cryptococcal meningitis

Answer 6

Headache, meningism, focal neurology
CSF: CrAg and culture

Treatment:
Induction: flucytosine + fluconazole + single dose amphotericin B
Fluconazole consolidation

Question 7

Molluscum contagiosum in HIV

Answer 7

Poxvirus
Can become widespread (IRIS)
Differentials: cryptococcus, histoplasmosis, talaromycosis

Question 8

Hepes zoster in HIV

Answer 8

Reactivation of VZV –> painful vesicles that do not cross the midline
Valaciclovir/IV aciclovir

Question 9

Papular pruritic eruption in HIV

Answer 9

Eosinophilic foliculitis - cause unknown - symmetrical itchy papulaes on the face/trunk/extremeties

Question 10

Chronic diarrhoea in HIV - causes

Answer 10

HIV itself
Medication
Infections
- Cyptosporidium - ART
- CMV colitis
- TB
- Schistosomiasis
- Amoebiasis
- NTM

Question 11

Oesophageal lesions in HIV - causes

Answer 11

Oesophageal candidiasis
CMV
Malignancy

Question 12

Oral hairy leukoplakia

Answer 12

EBV related, no specific treatment

Question 13

PCP in HIV - diagnostics and treatment

Answer 13

PCR +/- microscopy on BAL/sputum
BD glucan
Treatment: co-trimoxazole

Question 14

What is kaposi sarcoma?

Answer 14

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

Question 15

How do you make a diagnosis of HIV?

Answer 15

2 serological assays p24 AG +/- AB
Immunotyping for HIV1/2
Viral load (quantitative PCR)

Question 16

Whats the first line combination treatment for HIV (as per WHO guidelines, no Hep B)

Answer 16

Tenofovir disoproxil fumarate (TDF) + Lamivudine (3TC) or Emtricitabine (FTC) + Dolutegravir (DTG)

Question 17

When to start treatment for HIV?

Answer 17

ASAP EXCEPT:
Cryptococcal meningitis
TB meningitis

Question 18

What kind of virus is HIV?

Answer 18

Retrovirus - i.e. inserts a DNA copy of its genome into the host cell to replicate

Question 19

What are some things to check before initiating on ART?

Answer 19

HTN
CVD
DM
Pregnancy
TB
LFTs
Proteinuria
Hepatitis B surface antigen

Question 20

NRTI

Answer 20

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

Question 21

NNRTI

Answer 21

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

Question 22

Protease inhibitors in HIV

Answer 22

Atanivir, ritonavir

Severe liver disease
Hyperlipidaemia
Hyperglycaemia
Avoid in CVD
Advise giving in renal disease

Question 23

Integrase inhibitors in HIV

Answer 23

Dolutegravir
Weight gain, hypersensitivity, hepatotoxicity
Harmlessly can increase creatinine - usually plateaus at week 4 and should not be progressive

Question 24

HIV associated nephropathy (HIVAN)

Answer 24

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

Question 25

Progressive multifocal leukenencephalopathy (PML) in HIV

Answer 25

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

Question 26

HIV patient presenting with headache, confusion and drowsiness. Her CT shows multiple ring enhancing lesions with some surrounding odoema

Answer 26

Toxplasmosis

Mx: sulfadiazine and pyrimethamine (+folinic acid)

Question 27

HIV patient presenting with weight loss and a single homogenous enhancing lesion on CT brain

Answer 27

Lymphoma

Question 28

Patient with HIV presenting with headache, fever, malaise and seizures. LP - lymphocytosis and high opening pressure. CT shows meningeal enhancement and cerebral odoema

Answer 28

TB
Cryptococcal meningitis

Question 29

HIV patient with subacute speech and motor impairment with hemianopia. CT shows multiple non-enhancing lesions.

Answer 29

PML

Question 30

Approach to lymphadenopathy in HIV

Answer 30

Any CD4 count
TB
Syphilis
Lymphoma
KS
NTM

CD4 <100
Dimorphic fungal infections
Nocardia
Cryptococcus

Question 31

Which ART is it normal to have a raised bilirubin?

Answer 31

Atazanavir (ATZ)

Question 32

Which ART class is most linked with resistance and should be switched if there is a rebound jump in viral load?

Answer 32

NNRTI