HIV Flashcards
What is seroconversion in HIV?
What are the common symptoms of Primary HIV infection?
Seroconversion occurs when antibodies are produced against the virus.
PC: glandular fever-like illness (sore throat, fever, swollen glands)
fever,
inflammation- arthralgia, headaches, neuralgia, malaise
diarrhoea, maculopapular rash
meningitis, neuropathy, encephalopathy
What are the neurological manifestations possible in seroconversion of HIV?
- aseptic meningioencephalitis
self limiting headache, meningism, cranial nerve palsy, seizures - Guillain Barré syndrome- demyelinating polyneuropathy
unsual high WCC may be found on CSF if HIV +ve - Myelitis- inflammation may occur anywhere
- Cauda equina syndrome
- Myositis
What CD4 counts are associated with possible opportunistic infections in HIV?
CD4 below 200/mm3 = toxoplasmosis and cryptococcal meningitis
impaired inflammatory response- headache, no stiff neck or photophobia
CD4 below 50/mm3 = CMV
How would cryptococcal meningitis be investigated in HIV patient?
What needs to be excluded?
India ink stain
Cryptococcal antigens (c. neoformans) in blood + CSF
CSF culture
CSF- VRDL for neurosyphilis
TPPA (haemagluttination assay) for syphilis
HIV +ve patient
PC: started as a headache, now hemiparesis + dysphasia, visual problems etc
CT: multiple rounded abscess + mass effect
further IHx?
Toxoplasmosis- reactivated HIV, CD4
What prophylaxis against toxoplasma may be given?
When would it be given?
Co-trimoxazole if CD4 goes below 200
NB note it is the same as PCP prophylaxis
HIV +ve
PC: headache, confusion, Kernig’s sign negative
what test is needed to diagnose cryptococcus neoformans?
95% have cryptococcal antigen in CSF
Gold standard: CSF culture (85% are positive)
India ink stain
Meningitis without classic neck stiffness and photophobia.
On a CT scan, what makes a diagnosis of toxoplasmosis more likely in a HIV patient compared to progressive multifocal leucoencephalopathy (due to Creutzfeldt Jakob papovirus reactivation).
In toxoplasmosis, mass effect may occur and tends to be multiple lesions.
In CJ virus reactivation, there may only be a single lesiona and no mass effect occurring.
Both lesions tend to occur at the white/grey interface.
If progressive multifocal leucoencephalopathy is suspected in a HIV +ve patient what investigations should be done?
PC: hemiparesis, confusion, 7th CN palsy, dysphasia (language), visual problems.
IHx: CT/MRI looking for brain lesions (single could be JC virus or CNS lymphoma)
CSF PCR
(+ve in 75%) looking for Cruetzfeldt Jakob virus
If negative result, biopsy may be performed.
MRI: cortical atrophy with patches of white matter with high signal.
HIV +ve patient with increasing memory loss and poor concentration.
HIV-associated dementia
Diagnosis of exclusion- exclude depression, substance abuse, neurosyphilis and cerebrovascular disease
Rx: HAART with zidovudine
What is the commonest neurological complication in HIV?
Distal sensory peripheral neuropathy- like in diabetes
30% of symptomatic AIDS patients get it.
Can be a side effect of nucleoside analogues as well, which gives a dose dependent, reversible neuropathy lasting 6 weeks after the drug is stopped.
HIV patient found to have multiple lesions on CT is treated with sulfadiazine and pymethamine. This has not helped. What should be done next? What is the most likely diagnosis?
Biopsy the mass.
Primary CNS lymphoma.
CSF +ve for Epstein Barr virus- thought to be associated- but often contraindicated due to high pressure in brain.
Even with whole brain radiotherapy, prognosis is very poor, so may not biopsy unless a treatable pathology is considered likely.
What CD4 count makes cryptococcus meningitis more likely?
CD4 below 100 cells/uL
Cryptococcus is an encapsulated fungi.
What are the stages/groups of HIV infection?
CDC 1992
- primary HIV infection (seroconversion)
- asymptomatic phase
- persistent generalised lymphadenopathy
- symptomatic infection
Group 4 subdivides into A-E categories according to AIDs-defining conditions present
What features need to be present to define Group 3 phase in HIV?
Generalised lymphadenopathy-
lasts at least 3 months
2 extra-inguinal sites
not due to any other cause (bacterial, malignant or sarcoid-esque)
How is Group IVA- HIV wasting syndrome defined?
10% loss of weight
fever lasting 1 month +
Diarrhoea lasting 1 month +
Rx: exclude other causes, antipyretics, antidiarrhoeal agents and finally steroids.
HIV +ve patient with a red scaly rash over face and scalp.
Seborrhoeic dermatitis
Rx: 1% hydrocortisone and antifungal cream
Common skin problems with HIV and how to treat:
a. tinea cruris
b. vaginal candida
c. oral candida
d. shingles
e. perianal warts
Tinea cruris (crotch) -clotrimazole cream
Candidiasis- clotrimazole cream
Oral candidia - nystatin or fluconazole
Shingles- aciclovir/ famciclovir
Recurrent perianal or genital warts - long term aciclovir
What effects on blood count may be expected in HIV
low neutrophils- neutropenia
normochromic normocytic anaemia
thrombocytopenia- low platelets
(if bleeding or below 20 need to give antiretrovirals)
HIV meds may be toxic to the bone marrow
which malignancies are deemed AIDs-defining?
Kaposi’s sarcoma
High-grade B-cell non-Hodgkin lymphoma
Invasive cervical carcinoma
Which virus is associated with kaposi’s sarcoma and body cavity lymphoma?
Human herpes virus 8
Which virus is associated with non-hodgkins lymphoma?
Epstein Barr virus
What virus is associated with hepatocellular carcinoma in HIV?
Hepatitis B and C
HPV may cause warts and which other problems?
Anogenital or oral carcinomas
How is Human Herpes Virus 8 spread?
Sexual transmission- unlikely to be via semen
Mother to child
Organ transplant
HIV patient
extensive lymphadenopathy
what would you be worried about?
Castleman’s disease- not technically a cancer but lymph node proliferation.
IHx: biopsy
HHV8 virus
What factors suggest a good prognosis for Kaposi’s sarcoma?
Localised disease -rather than systemic lymph node enlargement
CD4 above 150 cells/microL
No systemic symptoms
can give HAART alone
How can Kaposi’s sarcoma be treated?
LOCAL
Repeat cryotherapy- may leave scar
Radiotherapy- if lesions are painful or causing lymphatic obstruction
May cause erythema, hair loss, pigmented scarring.
Intra-lesional chemicals for mucocutaneous lesions:
VINBLASTINE or VINCRISTINE
Causes painful inflammatory response before clearance of lesion.
WIDESPREAD- good prognosis
HAART
If patient has poor prognostic factors Kaposi’s sarcoma what treatment should they get?
HAART + Liposomal DAUNORUBICIN or DOXORUBICIN
SEs: 50% neutropenia, alopecia, vomiting
Need PCP prophylaxis
(HAART alone if poor prognosis)
What type of non-hodgkins lymphomas are associated with HIV?
Aggressive B cell types:
diffuse large B-cell lymphomas
Burkitt’s lymphoma
non- Burkitt’s lymphoma
rarely primary CNS lymphomas
What might a typical regime for non-hodgkins lymphoma in HIV look like?
HAART + CHOP cyclophosphamide hydroxydaunomycin oncovin (vincristine) prednisolone
single lesion on MRI. Patient is HIV +ve
which investigations help distinguish between differential?
CSF:
EBV- human herpes 4 PCR
cytology
JC virus PCR
toxoplasma IgG
SPECT- single photo electron CT, hyperactive lesion suggests lymphoma
failure after 2 weeks to respond to toxoplasmosis treatment
Hodgkins disease in HIV is more likely and more aggressive.
How to treat?
HAART + ABVD
doxorubicin, bleomycin, vinblastine, dacarbazine
How would you treat a patient who was found to have concurrent HIV and TB?
Treat the TB first, as per normal and not the HIV- generally (Rifamipicin interacts with HAART)
then after two months when TB drugs change to two medications, add HAART
HIV patient and fundoscopy, see cotton wool spots, what might be the cause?
Retinopathy (from HIV-vasculopathy)
Cotton wool spots- infarcts in neurones
Differ from CMV lesions as small, superficial and less frequent retinal haemorrhages and microaneurysms.
HIV patient is started on HAART, gets macular oedema, inflammation of eye and epi-retinal membrane formation (visible as a film on fundoscopy that causes puckering of the retina). What could be cause and treatment?
Immune recovery uveitis
Systemic steroids
What opportunistic infections do you get in the eye with HIV?
CMV infection- multiple floaters, blurring
Varicella zoster virus- (HHV3) vesicular eruptions of face, conjunctivits, uveitis
Herpes Simplex Keratitis- painful corneal ulcers
Toxoplasma retinochoroiditis- retinal lesions
Candida
Kaposi’s sarcoma
What kind of CD4 count puts patients at risk of CMV?
Below 100 cells/uL
should offer regular dilated examination of the fundi
HIV patient complains of floaters and some flashing lights in their vision. Diagnosis + Rx?
CMV -retinitis and vessel occlusion leading to necrosis
IHx vitreous sample CMV PCR or clinical
Repeat retinal photographs to track progression
Rx: HAART + intraocular GANCICLOVIR
SEs bone marrow suppression, GI upset
Most common cause of necrotising retinitis in HIV?
Rx?
Varicella zoster virus
Valaciclovir PO
What lumbar puncture opening pressure prompts therapeutic draining in cryptococcus infection with HIV?
Above 20cmH20
Which stain is needed to identify cryptococcus fungi on microscopy?
India ink stain not gram stain.
What secondary prophylaxis should be given for cryptococcal meningitis until CD4 count is above 150?
Fluconazole
Give until antigen ve and CD4 >150
Rx and prophylaxis of CNS toxoplasmosis in HIV?
Rx:
sulfadiazine + pyrimethamine (anti folate)
dexamethasone- if risk of coning from mass effect
Prophylaxis: co-trimoxazole
Complication to watch out for with cryptococcal meningitis, and prevention? (in HIV)
Intracranial hypertension leading to visual failure or death
Rx: daily lumbar punctures to relieve pressure
Cryptococcal meningitis Rx in HIV?
Rx: Amphotericin B + 5-flucytosine
HIV associated infection that is a notifiable disease?
Hepatitis
Which herpes virus is associated with CNS lymphoma in HIV?
Ebstein Barr virus (HHV4)
