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Tropical disease > HIV > Flashcards

HIV Flashcards

1
Q

cells infected by HIV

A

CD4 T cells
macrophages
dendritic cells

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2
Q

HIV important glycoproteins and their function

A

gp120 - binds CD4 receptor and co-receptor (CXCR4 or CCR5)

gp41 - promotes fusion of viral and cellular membranes

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3
Q

Risk of MTCT - without intervention

  • with BF
  • with HAART
A

15-40% without intervention
15-29% from BF
<2% with HAART

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4
Q

Acute HIV infection - time after

A

3-10 weeks

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5
Q

AIDS definition

A

CD4<14%

AIDs defining illnesses (opportunistic infections)

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6
Q

Clinical manifestiations of CD4 >200

A 
usually asympt
		Skin	candida vaginitis / oral
			Oral hairy leukoplakia 
Seb derm
			Shingles
			KS			
		Ca	CIN/Cx Ca
			B cell lymphoma
		Haem	ITP
			anaemia
Resp 	Bact pneumonia
	Recurrent URTIs
	Pulm TB
Other	Neuropathy
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7
Q

Clinical manifestations of CD4 100-200

A 
can be asympt
		Resp	PCP
			Histoplasmosis / coccidiomycosis
			Military/extrapulm TB
			Cardiomyopathy
		Neuro	neuropathies / myelopathy
			Dementia
			PML
		Other	wasting
			NHL
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8
Q

Clinical manifestations of CD4 <100

A 
can be asympt
		Fungal	candida oesophagitis
			Cryptococcus
		Viral	disseminated CMV
		Bact	disseminated MAC
		Parasite	toxo
			Microsporidiosis
			Chronic cryptosporidiosis
		Ca	CNS lymphoma
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9
Q

Benefits of ART

A 
prevent OI, Ca
Alter/reverse course of existing OIs
Improve/preserve immune ftn
↓ Sx
↑ QOL
Restore hope
↓ transmission
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10
Q

NRTI - least to most toxic (roughly)

A 
Lamivudine 3TC
Emtricitabine FTC
Tenofovir TDF
Abacavir ABC
Zidovudine AZT
Didanosine ddI
Stavudine d4T
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11
Q

NRTIs active against hep B

A

lamivudine 3TC

tenofovir TDF

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12
Q

problem with abacavir (ABC) and how to prevent

A

hypersensitivity rxn 3-7% - mortality

predict with HLA-B5701 test

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13
Q

NRTI class toxicities

A 
mitochondrial toxicity - neuropathy, LA
lipodystrophy
myopathy
hepatitis
pancreatitis
hyperlipidaemia
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14
Q

Lactic acidosis RFs

A 
female
older age
high BMI
- esp d4T, ddI, combination +
- esp 1st 3/12 Rx
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15
Q

Lactic acidosis Sx

A 
A, N, V, AP
pancreatitis, hepatitis
SOB, arrhyth
multi-organ failure, death
= increased anion gap + lactate
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16
Q

Lactic acidosis management

A
  • obtain venous sample w/o tourniquet
  • stop ARV if symptomatic + high lactate
  • supportive Rx
  • no d4T, ddI or AZT in next regimen
  • routine monitoring not required
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17
Q

NNRTI class toxicities

A

rash

hepatotoxicity

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18
Q

NNRTI features

A

long half-life 2-3 wks
lots of drug interxns
not active vs HIV-2 or group O
risk resistance

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19
Q

preferred TB PI

A

efavirenz

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20
Q

Nevirapine risk and RFs for it

A 
hypersensitivity rxn (rash, hepatotoxicity)
- esp men with CD4>400, women CD4>250
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21
Q

benefits of boosting PIs with ritonavir

A 
increased PI level b/c of less metabolism from cyt p450 inhibition
fewer pills
more predictable efficacy and activity
lower toxicity
less resistance
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22
Q

preferred PI in pregnancy

A

lopinavir/ritonavir

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23
Q

IRIS DDx

A 
relapse
resistance
drug toxicity
new disease process
- Rx dilemma: stop/continue ART, stop/change OI Rx, anti-infly agent, immunosuppressives
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24
Q

risks of starting ARV at low CD4

A

higher risk OI
higher risk toxicity
non-AIDS related complications more common (CVD, Ca, liver, renal disease)

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25
Q

ARVs to avoid in TB

A

PIs - interxn with rifampicin

NVP - use EFV instead (can use if needed)

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26
Q

Treatment failure WHO definition

A

Clinical - new/recurrent stage 4 condition (IRIS excluded)
Immunological - fall of CD4 to baseline / 50% from peak
Virological - VL >5000

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27
Q

Indications for TMP/SMX prophylaxis of toxo/PCP

A 
CD4 not available
- WHO stages 2,3,4
CD4 available
- CD4<350 (LMIC)
- WHO stages 3,4
Alt - all PLHIV
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28
Q

3 I’s for HIV/TB

A

Intensified case finding for active TB
Infection control for TB at all clinical encounters
INH preventive treatment - latent TB prevalence >30%
- all with documented latent TB

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29
Q

Meningitis in HIV pts - causes

A 
cryptococcus
TB
syphilis
bacterial - strep, listeria
viral
fungal
lymphoma
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30
Q

CNS mass lesion in HIV pts - causes

A 
Common
- toxo *
- tuberculoma
- lymphoma
Less common
- cryptococcoma
- PML
- bacterial abscess
- other (syphilis, tumor, Chagas, Nocardia, Aspergillus)
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31
Q

Rx crypto meningitis

A

ampho B + flucytosine / fluconazole 800mg

or flucyt+flucon 1200mg or flucon 1200mg

32
Q

Rx cerebral toxo

A

pyrimithemine + sulfadiazine (+ folinic acid)

alt clind+pyrimeth, high dose TMP/SMX, dapsone, atovaquone

33
Q

Radiologic characteristics of CNS masses in HIV

A 
Enhancement with contrast
- toxo (ring enhancing)
- lymphoma (ring or diffuse enhancement)
- tuberculoma (diffuse enhancement)
Non enhancing
- crypto
-PML
# lesions
- toxo (multiple)
- lymphoma (single / multiple)
- tuberculoma (single / multiple)
34
Q

5 min neuro screen:

strength ok but slow mentation

A

HIV dementia

35
Q

5 min neuro screen:

cauda equina syndrome

A

CMV radiculitis

36
Q

5 min neuro screen:

pain in feet, decreased DTRs

A

sensory neuropathy (‘d’ drugs)

37
Q

seizures, focal deficits

A

toxo

38
Q

subacute progressive deficits

A

PML

39
Q

ICP elevation

A

crypto

40
Q

most common cause of retinitis in AIDS

A

CMV

41
Q

CMV retinitis lesions

A

2/3 unilateral
‘cheese and ketchup’
uveitis rare

42
Q

CMV retinitis Rx

A

iv gangiclovir /
PO valganciclovir if lesions not sight-threatening
2-3 wks
follow with secondary prophylaxis

43
Q

Common lung disease aetiologies in HIV

A

TB
PCP (pneumocystis jiroveci)
bacterial
fungal

44
Q

Commonest cause of bacterial pneumonia in HIV

A

pneumococcus (100x increased risk)

45
Q

CXR in HIV

A

normal - PCP, TB, fungal, bronchitis
Diffuse infiltrates - PCP, TB, fungal, KS, CMV, LIP
Focal airspace - TB, fungal, bacterial, nocardia
PTx - PCP
Nodules/cavities - TB, fungus, staph, nocardia, rhodococcus, KS, endocarditis
Adenopathy - TB, fungus, MAC, lymphoma
Pleural effusion - TB, bacterial, KS, lymphoma, uremia, CHF, hypoalbuminaemia

46
Q

Normal CXR in HIV lung disease

A

PCP
TB
fungal
bronchitis

47
Q

Diffuse infiltrates on CXR

A 
PCP
TB
fungal
KS
CMV
LIP
48
Q

Focal lesions on CXR

A

TB
fungal
bacterial
nocardia

49
Q

PTx on CXR

A

PCP

50
Q

Nodules / cavities on CXR

A 
TB
Fungus
staph
nocardia
rhodococcus
KS
endocarditis
51
Q

Adenopathy on CXR

A

TB
fungal
MAC
lymphoma

52
Q

Pleural effusion on CXR

A 
TB
bacterial
KS
lymphoma
uraemia
CHF
hypoalbuminemia
53
Q

Oesophageal disease in HIV

  • aetiology
  • sx
  • management
A 
candida
CMV
HSV
TB
fungi
cancer
idiopathic
- CD4 <100
- dysphagia / odynophagia, CP
 - empiric Rx candida (fluconazole 100-200mg 2/wks); EGD & Bx if no response
54
Q

Diarrhoea etiology in HIV

A 
TB
MAC
bacteria (salmonella, shigella, E coli, SI bact overgrowth)
protozoa (crypto, isospora belli, microsporidium, giardia, cyclospora, E histolytica, strongyloides)
fungi (histoplasmosis)
virus (CMV, HSV)
HIV (AIDS enteropathy)
malignancies (KS, lymphoma)
drugs (PIs, ABx)
55
Q

Etiologies if large volume diarrhoea

A

small bowel disease

  • cryptosporidium
  • microsporidium
  • cystoisospora
  • giardia
56
Q

Etiologies if small volume diarrhoea

A

colitis / proctocolitis - tenesmus, bld, mucus

  • shigella
  • campylobacter
  • C diff
  • HSV
  • CMV
57
Q

Hepatobiliary disorders in HIV

A 
Viral hepatitis
OIs - MAC, TB, bartonella, endemic fungi
Malignancies
Drugs - HAART, anti-TB, ABx, statins, psy
Cholangitis - MAC, crypto, microsp, CMV
58
Q

Potential reasons for non infectious complications of HIV

A 
chronic immune system stimulation
chronic inflammation
premature aging
mitochondrial damage (esp d drugs, NRTIs)
drug toxicity
59
Q

Spectrum of HAND (HIV-associated neurocognitive disorder)

A

ANI - asympt neurocog impairment
MND - minor neurocog disorder
HAD - HIV-associated dementia

60
Q

AIDS-defining cancers

A

Kaposi’s sarcoma
Primary CNS lymphoma
NHL
invasive Cx Ca

61
Q

AIDS-associated cancers (not AIDS-defining)

A

primary effusion lymphoma

SCC conjunctiva

62
Q

Cancers with increased incidence in HIV (not dependent on CD4)

A 
liver cancer
Hodgkin's disease
anal cancer
melanoma
oropharyngeal cancer
lung cancer
63
Q

Cause of Kaposi’s sarcoma

A

Human herpesvirus 8

64
Q

Anaemia in HIV - frequency

- causes

A 
70-80% patients with advanced disease
Anaemia of chronic disease
Drugs - AZT, cotrim, dapsone, primaquine
Infections - parvo B19, fungi, TB
Nutritional - iron, folate, B12, scurvy, Cu
Malignancies, myelodysplasia
65
Q

Leukopenia in HIV - frequency

- causes

A 
50% patients with advanced disease
Due to HIV
Drugs - AZT, cotrim, sulfas, pyrimethamine, ganciclovir, ABx
Infections - MAC, TB, fungi, parvo B19
Malignancies, myelodysplasia
66
Q

Thrombocytopenia in HIV - frequency

- causes

A

40% patients - may be early sign of HIV
Periph destruction due to autoantibodies
- HIV, drugs
BM probs - infections, malignancy

67
Q

Bicytopenia / pancytopenia in HIV

- causes

A 
Malignancies - lymphoma, KS
Infections - TB, MAC, VL, parvo B19, histo, cocci, crypto
Aplastic anaemia, myelodysplasia
Nutritional
Drugs
68
Q

Dyslipidaemia in HIV - causes

A

HIV

ARVs - esp boosted PIs, also NRTIs, efavirenz

69
Q

Why is CVD more common in HIV?

A 
HIV
- dyslipidemia
- endothelial damage
- vascular dysftn
- chronic inflammation
- procoagulant factors
- lipodystrophy
ART
- dyslipidemia
- endothelial dysftn
- HT
- insulin R
- fibrinogen levels
- lipodystrophy
70
Q

Bone disease in HIV

A 
High prevalence osteopenia (25-60%), osteoporosis (10%)
Possible causes
- HIV
- cytokines
- ARV
- lifestyle
- MN, hypogonadism, acidosis
- vit D insufficiency
- liver disease
Increased # rate in HIv
71
Q

Type of HIV most common in Western world

A

subgroup B, group M, type 1

72
Q

Type of HIV most common sth Africa (worldwide)

A

subtype C, group M, type 1

73
Q

Common toxicities with ARVs

A

AZT - anaemia
Tenofovir - tubular toxicity (take for hep B)
Lamivudine - lovely (& FTC) (like for hep B)
Abacavir - allergy affecting life
Efavirenz - effects on baby, eccentric dreams, excellent in TB
Nevirapine - nukes the liver, hypersens, near-normal CD4 esp a prob

74
Q

Important ARV components in hep B pts

A

TDF + lamivudine/emcitrabine

75
Q

Cotrimoxazole prophylaxis - indications and benefits

A

WHO clinical stage 2,3,4
CD4<200 for PCP/toxo
Benefits - reduced mortality by 50% in severely immune-suppressed HIV-infected adults initiating ART, for at least 72 weeks. - reduced malaria incidence in these pts

76
Q

Most frequent life-threatening OI and leading cause of death in HIV

A

TB

77
Q

Three Is strategy

A

Isoniazid preventive treatment (IPT)
intensified case finding (ICF) for active TB
TB infection control (IC)
(pre-ART care setting)

Tropical disease (24 decks)

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