HIV Flashcards
_____ is the dominant type in the United States and worldwide
HIV-1
_____ is found mainly in West Africa and has a slower/faster clinical course
HIV-2, slower
Acute retroviral syndrome symptoms often mimic ______.
Symptoms often mimic infectious mononucleosis
Typical onset of symptoms _ to _ weeks after exposure to HIV (_ to _ weeks most commonly), but it may manifest up to _ months later
Typical onset of symptoms 1 to 6 weeks after exposure to HIV (2 to 3 weeks most commonly), but it may manifest up to 6 months later
Acute retroviral syndrome: most common presentation?
Most common presentation: fever, lymphadenopathy, pharyngitis, rash , myalgias, and arthralgias
Which OIs: CD4 > 500
Acute retroviral syndrome HIV-associated nephropathy
OIs : 200 < CD4 < 500
Oral candidiasis Community-acquired pneumonia Pulmonary TB Kaposi sarcoma Herpes zoster
When do we start chemoprophylaxis against OIs?
CD4 < 200
Chemoprophylaxis 100 < CD4 < 200?
trimethoprim-sulfamethoxazole or dapsone or atovaquone or aerosolized pentamidine For: PCP
OIs/associated conditions for CD4 less than 200?
PJ pneumonia (PCP) Disseminated histoplasmosis Extrapulmonary TB Wasting HIV dementia
OIs/associated conditions for CD4 < 100
CNS toxoplasmosis Cryptococcosis CNS lymphoma
Chemoprophylaxis for 100 < CD4 < 200?
Toxoplasmosis prophylaxis (if toxo IgG+) trimethoprim-sulfamethoxazole or Dapsone/pyrimethamine/folinic acid or atovaquone
Chemoprophylaxis against MAI
CD4 < 50
What chemoprophylaxis regimes when CD4 < 50?
MAI prophylaxis with azithromycin or clarithromycin
What OIs/associated conditions with CD4 < 50?
Disseminated MAI Disseminated CMV Progressive multifocal leukoencephalopathy
CD4 count lower than ___/mm3 or the presence of an indicator condition defines AIDS
200
A patient is ELISA +ve for HIV. What is the next step?
Confirm with Western blot
What does the HIV ELISA test for?
The HIV antibody
When does the HIV antibody test become positive?
Positive 3 to 4 weeks after acute infection
When does the HIV RNA viral polymerase chain reaction (PCR) become positive?
Positive 3 to 5 days after acute infection
HIV RNA PCR is the test of choice in diagnosis of acute HIV infection, although count _____ may be false positive
lower than 10,000 copies/mm3
Why do we test for HIV genotype following a positive HIV test?
Nationwide, 10% to 20% of patients with new HIV infection have transmitted resistance to at least one class of antiretroviral medications
Six main classes of antiretroviral agents
Nucleoside Reverse Transcriptase Inhibitors Non-nucleoside Reverse Transcriptase Inhibitors Protease Inhibitors Membrane Fusion Inhibitors CCR5 Antagonist Integrase Inhibitor
Which class do the following drugs belong to: Zidovudine (AZT) Stavudine (d4T) Didanosine (ddI) Lamivudine (3TC) Emtricitabine (FTC)
NRTI
Which class: Abacavir, tenofovir?
NRTI
Which HIV drug is associated with: Renal insufficiency and Fanconi syndrome
tenofovir
A patient with HIV, on abacavir, presents with fever, rash, flu-like symptoms. Next step?
Discontinue drug. Usually in first 2–6 wk after starting Can be fatal if drug not discontinued
Which NRTI causes bone marrow suppression?
AZT
Which 2 NRTIs cause peripheral neuropathy?
Stavudine (d4T), Didanosine (ddI)
Side-effects of AZT
Bone marrow suppression Lactic acidosis
Side-effects of d4T
Peripheral neuropathy Lipodystrophy Lactic acidosis
Side-effects of ddI
Peripheral neuropathy Pancreatitis Lactic acidosis
3TC is:
Lamivudine
FTC is:
Emtricitabine
Nevirapine, Efavirenz, Etravine are:
NNRTIs
Which teratogenic NNRTI can cause confusion and nightmares?
Efavirenz
Which NNRTI can cause Stevens-Johnson syndrome?
Nevirapine
What side-efects are common to PIs?
Diarrhea, lipodystrophy, central obesity with peripheral wasting, hyperlipidemia, and insulin resistance
Which PI can cause hyperbilirubinemia?
Atazanavir
Which category of anti-HIV drugs do the following belong to: Atazanavir Darunavir Fosamprenavir Indinavir Lopinavir Nelfinavir Ritonavir Saquinavir Tipranivir
All protease inhibitors
Which protease inhibitor can cause nephrolithiasis?
Idinavir
Which 2 do not belong? Abacavir Atazanavir Darunavir Fosamprenavir Indinavir Lopinavir Nelfinavir Ritonavir Saquinavir Tenofovir Tipranivir Bacavir
Abacavir, tenofovir are NRTIs; the others are PIs.
Enfuvirtide: which class?
Membrane fusion inhibitor
Maraviroc: which class?
CCR5 Antagonist
What is the problem with maraviroc?
Well tolerated, but only effective against CCR5 tropic virus
Raltegravir: which class?
Integrase inhibitor
Initiate (ART) once the CD4 count declines to less than ___/mm3 or when _____ are present
Initiate antiretroviral therapy (ART) once the CD4 count declines to less than 500/mm3 or when symptoms are present
Which HIV+ should all be treated regardless of CD4?
Pregnant women, patients with HIV-associated nephropathy (HIVAN), and patients undergoing treatment for hepatitis B
Combination HIV therapy
3 antiretroviral agents from at least 2 different classes
The best choice of initial regimen is:
The best choice of initial regimen remains controversial
How many different types of initial therapy?
4 Efavirenz/tenofovir/emtricitabine Ritonavir-boosted darunavir plus tenofovir/emtricitabine Ritonavir-boosted atazanavir plus tenofovir/emtricitabine Raltegravir plus tenofovir/emtricitabine
ETE
Efavirenz + tenofovir + emtricitabine
RDTE
Ritonavir-boosted darunavir plus tenofovir+emtricitabine
RATE
Ritonavir-boosted atazanavir plus tenofovir/emtricitabine
RTE
Raltegravir + tenofovir/emtricitabine
Goal of therapy
▪ Goal of therapy is viral suppression, which means that the viral load is undetectable or lower than 200 copies/mm3
CD4 count and viral load measured _ to _ weeks after initiation or change of therapy and every _ to _ weeks once viral load suppressed
CD4 count and viral load measured 2 to 8 weeks after initiation or change of therapy and every 12 to 24 weeks once viral load suppressed
When should the ART regimen be changed?
ART regimen should be changed if patient fails to achieve virologic suppression in 24 to 48 weeks or has an increase in viral load (>1000 copies/mm3)
If the patient has side-effects to a particular drug and his viral load is undectable: is it acceptable to switch a single agent?
Yes
PEP should be given with combination of __ drugs for lower-risk exposures and ___ drugs for higher-risk exposures
PEP should be given for both percutaneous and mucocutaneous exposures with a combination of two drugs for lower-risk exposures and three drugs for higher-risk exposures
PEP should be given: (first dose within __ hours) but is effective up to __ hours after exposure
PEP should be given without delay (first dose within 1–2 hours) but is effective up to 72 hours after exposure
High-risk factors for percutaneous transmission include hollow needle, visible blood, needle in vessel, and high viral load
Hollow needle Visible blood Needle in vessel High viral load
PrEP
Daily tenofovir/emtricitabine
PrEP via administering daily tenofovir/emtricitabine to high-risk HIV-negative men who have sex with men (MSM) has been shown reduce risk of acquiring HIV by __% while condoms reduce risk by _%.
44% , 90%
Why should candidates for PrEP be tested for Hepatitis B?
Hepatitis B because this regimen is also active against hepatitis B, and patients may have a hepatitis flare when discontinued
Which vaccines should be avoided in HIV+ patients?
live, attenuated virus vaccines MMR, Varicella
Which vaccines should be administered to HIV+ patients?
Hepatitis A Hepatitis B Pneumococcus Influenza Tetanus-diphtheria
When should we get PPD on HIV+ patients?
At diagnosis Annually if patent is at risk
PPD is positive in a HIV+ when?
> 5 mm
Cancer screening in HIV+ patients: what is different?
Cancer screening is as per usual guidelines with the exception of cervical cancer (8- to 10-fold elevated risk in HIV patients)
When should we get the PAP smear in HIV+ patients?
At Diagnosis After 6 months Annually, thereafter, if normal
Oropharyngeal creamy white plaques
Oral candidiasis
Painless, white, nonremovable plaques, usually on the lateral and dorsal tongue
Oral hairy leukoplakia
Which virus is Oral hairy leukoplakia (OHL) associated with?
Epstein-Barr
Causes of odynophagia in a HIV+ patient
Candidal esophagitis cytomegalovirus (CMV) herpes simplex virus (HSV) aphthous ulcers
Ddx: Odynophagia in HIV patient with low CD4 count
Candia esophagitis
When is endoscopy necessary in a HIV+ patient with odynophagia?
When empiric therapy for candidiasis fails.
Rx: Candidal esophagitis
2-weeks fluconazole
What additional coverage do you need for CAP in a HIV+ patient with low CD4?
Typical CAP pathogens + Gram negative coverage
Characteristic CXR appearance of PJ pneumonia
“Bat wing” perihilar infiltrate 20% have normal chest radiograph
PJ pneumonia: CD4 count less than?
200
Ddx: Subacute onset of cough and fever in a HIV+ patient
PJ pneumonia Pulmonary histoplasmosis Tuberculosis
Characteristic CXR appearance of histoplasmosis
Diffuse interstitial infiltrates
Pulmonary TB in HIV+ patient, CD4 less than?
Any CD4 count Common if C4 < 200
Rx: PJ pneumonia, alternative to Bactrim
dapsone/trimethoprim; clindamycin/primaquine; atovaquone; or IV pentamidine Add
Rx: PJ pneumonia, hypoxic patient
Add corticosteroids if PaO2 <70 or A-a gradient >35
Dx: pulmonary histoplasmosis
Histoplasma urine antigen; bronchoalveolar lavage culture
Rx: pulmonary histoplasmosis
Itraconazole or amphotericin B
Rx: pulmonary TB in HIV+ patient
4-drugs for 2 months 2-drugs for 4 more months
Radiographic appearance of pulmonary TB in advanced HIV
Diffuse interstitial infiltrates Noncavitary in advanced HIV
4 common CNS conditions in HIV+ patients
Toxoplasmosis Lymphoma Cryptococcal meningitis Progressive multifocal leukoencephalopathy (PML)
Which CNS condition occurs with CD4 < 50?
Progressive multifocal leukoencephalopathy (PML)
Cx: Toxoplasmosis
Focal deficits Seizures
Dx: Toxoplasmosis
Toxo IgG+ in 90%
MRI appearance: toxoplasmosis
Multiple ring enhancing lesions therapy Clinical improvement MRI in 2 wk
Rx: toxoplasmosis
Sulfadiazine + pyrimethamine Suppressive therapy until CD4 >200 for >3 mo
Cx: CNS lymphoma
Focal deficits Seizures
Ddx: focal deficits in a HIV+ patient
Toxoplasmosis CNS lymphoma PML
Rx: PML
No specific therapy Antiretroviral therapy may be beneficial
Presentation:Cryptococcal meningitis
Severe headache High intracranial pressure Extra-CNS manifestations: skin lesions, pneumonia
Dx: Crypotococcal meningitis
CSF or serum cryptococcal antigen CSF culture
CSF +ve for cryptococcal antigen. Low WBC noted. Conclusion?
Poor prognosis
Cx: disseminated MAI
CD4 < 50 Non-specific and sensitive: fevers, malaise, wasting, abdominal pain, lymphadenopathy, anemia and leukopenia Sensitive and more specific: Elevated alkaline phosphatase
Dx: MAI
Blood cultures for weeks (EIA) used in Japan: IgA antibody to MAC-specific glycopeptidolipid core Sensitivity: 84 and specificity: 100% Granulomas on bone marrow, liver biopsy
Rx: Disseminated Mycobacterium Avium-Intracellulare
clarithromycin + ethambutol +- rifabutin
CD4 < 50, prophylaxis against MAI with?
Azithromycin
____ is most common end-organ complication of CMV
Retinitis is most common end-organ complication of CMV
CMV infection presents when CD4 count is lower than __/mm3
50
HIV patient presents with floaters and decreased vision. Ddx?
CMV retinitis
CMV retinititis: Retinal changes include __ ___ retinal infiltrates and hemorrhage
fluffy white retinal infiltrates and hemorrhage
CMV infection: sites include retina, __ , lung (___), and __.
GI tract (hemorrhagic ulcerations), lung (pneumonitis), and central nervous system (CNS) (encephalitis)
Fundoscopy: “ketchup and cottage cheese” lesions. Cause?
CMV retinitis representing perivascular hemorrhage and exudates
Dx: CMV infection at sites other than retina
PCR culture, viral inclusion bodies
Rx: CMV systemic disease
ganciclovir or foscarnet
Rx: CMV retinitis
Intraocular ganciclovir implants
Kaposi sarcoma. CD4 < __
200 to 400 Can be seen with a modestly depleted CD4 count (200–500/mm3 range)
Indurated or nodular violaceous growths on the skin or in any visceral organ
Kaposi sarcoma
Dx: Kaposi sarcoma
Biopsy
EtiologicAgent: Kaposi sarcoma
Human herpesvirus 8
Rx: Kaposi sarcoma
Chemotherapy Intra-lesional chemotherapy Regression with ART
Non-Hodgkin’s lymphoma in HIV+, CD4 < __
200
NHL in HIV+: what is characteristic about Presentation?
Extranodal presentation common (GI tract, visceral, bone marrow, body cavity)
NHL in HIV+: 70% are _-cell derived
B-cell
Dx: NHL
Biopsy if lesion accessible Thallium SPECT shows enhancement of lesions
How will you differentiate between CNS NHL and Toxoplasmosis?
Thallium (SPECT) lymphoma lesions often enhance, whereas toxoplasmosis does not
Rx: NHL in HIV+ patient
Chemotherapy brain radiation if CNS involvement ART
HIV Nephropathy: Presentation
nephrotic syndrome
HIV Nephropathy: Prognosis
if untreated, leads to renal failure over 1 to 4 months
Ultrasound HIV Nephropathy
Large, echogenic kidneys
Dx: HIV nephropathy
Biopsy shows FSGS
DDx: HIV nephropathy
heroin nephropathy drug toxicity (e.g., tenofovir, indinavir, trimethoprim-sulfamethoxazole), hepatitis-related nephropathy
Rx: HIV nephropathy
ART Steroids
Presentation: Immune Reconstitution Syndrome (IRS)
2-12 weeks after ART Paradoxical clinical worsening Rapid decline in HIV viral load and low CD4
Dx: Immune Reconstitution Syndrome (IRS)
High clinical suspicion Atypical OI presentation Presentation
Rx: Immune Reconstitution Syndrome (IRS)
Rx OIs Continue ART Steroids unproven
____ s the most common cause of infective endocarditis in injection-drug users.
S. aureus is the most common cause of infective endocarditis in injection-drug users.
Dx: 36-year-old female who has been newly diagnosed with HIV presents to the clinic with fever, weight loss, and watery diarrhea for the past 3 weeks. On examination, her temperature is 39°C; she has temporal wasting, thrush, and mild hepatosplenomegaly. Her laboratory data show a CD4 count of 22/mm3, aspartate aminotransferase 56 U/L, alanine aminotransferase 62 U/L, and alkaline phosphatase of 300 U/L. Fecal leukocytes and studies for ova and parasites are negative. Which of the following are true?
MAI
A 34-year-old woman with HIV and a CD4 count of 60/mm3 presents with fever, diplopia, and difficulty speaking for the past 4 days. Her most recent labs, drawn 4 months ago, document the following: reactive plasma reagin (RPR) (1:1 titer) with nonreactive fluorescent treponemal antibody (FTA), reactive cytomegalovirus (CMV) immunoglobulin G (IgG), nonreactive Toxoplasma IgG, and reactive varicella-zoster virus (VZV) IgG. A brain computed tomography (CT) scan is obtained in the emergency room and shows three low-density lesions in the left and right parietal cortex and in the posterior fossa. They are ring-enhancing with contrast infusion. DX?
Toxoplasmosis The results of serologies are often useful in two situations: (1) predicting the complications of AIDS for which a patient might be at risk, and (2) developing a differential diagnosis for a presenting complaint. However, they are not very useful here. The syphilis serologic results are compatible with a “biologic false-positive” reaction (reactive nontreponemal test, nonreactive treponemal test), making active syphilis infection unlikely. CMV and VZV do not cause Mass CNS lesions. Cryptococcus usually presents with a meningitis picture and uncommonly has a mass lesion. PML may cause multiple focal lesions but not ring enhancement. Toxoplasmosis is a common when the CD4 cell count declines to less than 100/mm3, and it does cause focal lesion often ring-enhancing on either CT or magnetic resonance imaging. Though serology is usually reactive in AIDS patients presenting with proven CNS toxoplasmosis, it can be negative in up to 15% of cases.
28-year-old previously healthy man presents to the emergency department with complaints of fever, nonproductive cough, and progressive fatigue for 3 weeks. 15-pound weight loss over the past 3 months. Temperature is 38.8°C, pulse 124 beats/min, respirations 28 breaths/min, and blood pressure 110/78 mm Hg. He has thrush in the oropharynx, but his chest is clear to auscultation and percussion. (WBC) count of 3200/μL (with 83% polymorphonuclear leukocytes, 6% bands, 5% lymphocytes, 3% eosinophils, 3% basophils); hematocrit of 31%; and arterial blood gases (room air) of pH 7.51, partial pressure of oxygen (PO2) 29 mm Hg, and partial pressure of carbon dioxide (PCO2) 62 mm Hg. A chest x-ray (CXR) shows bilateral interstitial infiltrates throughout all lung fields. Rx?
Trimethoprim-sulfamethoxazole and prednisone
26-year-old female recently treated for gonorrhea and chlamydia and with a history of occasional crack cocaine use presents with 1 week of fevers, muscle aches, loose stools, and a sore throat. She recently took in a stray cat, and removed a tick from her trunk 3 days before onset of her symptoms. She is sexually active with one male partner. On physical examination, she had a temperature of 39.3°C and a faint macular rash on her trunk. Mucosal ulcerations are visible in her posterior oropharynx along with pharyngeal erythema. She has pea-sized, anterior cervical lymph nodes but no additional findings. Laboratory tests reveal a white blood cell (WBC) count 4800/mm3, hematocrit 39%, aspartate aminotransferase 78 U/L, alanine aminotransferase 67 U/L, normal chest x-ray, negative Monospot, and nonreactive HIV serology. What is the most likely infectious cause of her symptoms?
HIV
27-year-old male HIV-positive construction worker presents to your office for his first appointment. His CD4 count is 140/mm3. He has been asymptomatic. He is married with two young children. He lives in a rural area but travels at times for his construction work. He has not had any regular medical care and does not believe he received any vaccinations as a child. Which vaccine should not be given? Tetanus-diphtheria Hepatitis A Measles, mumps, and rubella (MMR) Pneumovax Influenza
MMR
A 43-year-old man presents for HIV management. He has been on a regimen of tenofovir, emtricitabine, and efavirenz. Because of central nervous system side effects, his regimen was changed to tenofovir, emtricitabine, and ritonavir-boosted atazanavir. Indications for a screening lipid profile include At the initial visit Six months after changing therapy Only when starting a protease inhibitor Only if other cardiac risk factors are present A and B C and D
A and B
Which group of ART drugs cause increase in LDL?
Protease inhibitors
Which group of ART drugs cause increase in triglycerides?
triglycerides may increase dramatically with both protease inhibitor–based ART and efavirenz.
A 31-year-old woman presents for her first clinic visit. She was diagnosed with HIV 6 months ago when she was evaluated for weight loss. She has had no opportunistic infections. Her CD4 count is 190/mm3. Her main symptoms are weight loss, poor appetite, irritability, and feelings of suicide since receiving her diagnosis. Her husband died of an undiagnosed illness 2 years ago. She recalls that he also lost weight. She is currently caring for their three children. Her exam is unremarkable, but she is intermittently tearful. Which of the following factors are most likely to negatively affect her adherence to antiretroviral therapy? Low educational attainment Possible depression History of intravenous drug use Dependent children Low income level
Depression is associated with lower rates of access to the health-care system, as well as decreased rates of adherence and increased rates of HIV-associated death. Other factors that influence adherence include a poor social network, low self-efficacy ratings, and active substance abuse.
41-year-old man with HIV and an unknown CD4 count presents to reinitiate HIV primary care. He complains of difficulty swallowing for the past 2 weeks, characterized as a feeling of food sticking in his subxyphoid region. His examination is notable for the presence of white plaques on his buccal mucosa and in his posterior oropharynx, but the rest of his examination is unremarkable. The best management strategy is Obtain an exercise stress test Obtain a chest computed tomography scan Prescribe clotrimazole troches for 10 days Perform upper endoscopy to rule out cytomegalovirus or herpes simplex virus esophagitis Prescribe fluconazole for 7 to 10 days
Fluconazole Topical agents (such as clotrimazole troches) are effective for oral thrush, a systemic antifungal, such as fluconazole, is required for esophageal candidiasis.
-year-old man with HIV infection presents with complaints of tingling and numbness in his toes bilaterally that, over several weeks, have progressed to involve the soles of both feet. He now also has complaints of burning pain in the same area. He has remained on his first antiretroviral regimen, consisting of stavudine, lamivudine, and efavirenz. His current CD4 cell count is 324/mm3 and his viral load is less than 40 copies/mL. His physical examination reveals present, though diminished, reflexes at the ankles bilaterally. There is also hyperalgesia on sensory testing of the soles of his feet. Which of the following would be an appropriate management step? Substitute tenofovir for stavudine Substitute didanosine for stavudine Discontinue stavudine Discontinue lamivudine Continue antiretroviral therapy and initiate ibuprofen therapy
Substitute tenofovir for stavudine Neuropathy common toxicity with stavudine (d4T) and Didanosine (ddI). Lamivudine (Epivir; 3TC) does not cause neuropathy Need to maintain triple therapy. Tenofovir does cause sensory neuropathy.
40-year-old male with HIV infection and a CD4 cell count of 40/mm3 presents with fevers and progressive headache for 1 week. On examination, his temperature was 38.5°C and he appeared uncomfortable; his neck was supple and his neurologic exam was normal. Computed tomography (without contrast) was consistent with mild cortical atrophy. A lumbar puncture was performed, with an opening pressure measured at 280 mm H2O. Cerebrospinal fluid (CSF) showed 4 white blood cells (WBCs)/mm3 (100% monocytes), protein 52 mg/dL, and glucose 60 mg/dL. What type of organism is most likely the cause of infection? Fungus Gram-negative diplococcus Gram-positive diplococcus Mycobacterium species DNA virus
Cryptococcus neoformans Typical presentation due to Cryptococcus neoformans, which is a fungus, and is a common opportunistic complication of AIDS when the CD4 cell count is below 100/mm3. Elevated protein and WBCs (mononuclear cells) are common laboratory findings on evaluation, although a normal WBC count does not rule out cryptococcal meningitis in AIDS patients, and is, in fact, associated with higher mortality
7-year-old businessman presents with fever, headache, malaise, a penile ulcer, and a rash. His symptoms started 7 days ago. He is concerned about having recent unprotected sexual intercourse with a prostitute while on a business trip. HIV testing with a home self-testing kit was negative. On examination, his temperature is 38.8°C, he has mild posterior oropharyngeal erythema, and shotty cervical lymphadenopathy. He has a penile ulcer and a diffuse maculopapular exanthem over his chest, arms, and palms. What is the most appropriate next step? Rapid plasma reagin (RPR) for secondary syphilis Repeat HIV antibody HIV RNA polymerase chain reaction (PCR) Tzank test for disseminated herpes simplex virus
HIV RNA polymerase chain reaction (PCR)
Question 15 A 32-year-old scrub nurse sustained a needle-stick exposure from a solid-bore needle during a trauma surgery. The patient has known HIV infection, as well as hepatitis C and a history of poor compliance with his antiretroviral medications. Which of the following are true? Postexposure prophylaxis should be initiated after information is received about the patient’s antiretroviral resistance profile Hollow-bore needles, visible blood, and hepatitis C coinfection increase the risk of HIV infection Over 50% of health-care workers stop postexposure prophylaxis due to side effects Splash exposures are lower risk and do not require postexposure prophylaxis
Over 50% of health-care workers stop postexposure prophylaxis due to side effects Despite a risk of seroconversion of 0.3% following needle-stick injury from an HIV-positive source, less than 50% of health-care workers successfully complete the 4-week course of postexposure prophylaxis. Postexposure prophylaxis should be considered for both percutaneous and mucocutaneous exposures. When indicated, postexposure prophylaxis should be initiated without delay. Increased risk of transmission is associated with hollow needles, visible blood, a needle in a vessel, and high viral load. Hepatitis C coinfection has not been associated with increased risk of transmission.
A 30-year-old construction worker with a CD4 count of 240/mm3 presents for his annual physical. His social history is notable for smoking one-half pack of cigarettes per day. He is a former intravenous drug abuser but has not used in over 5 years. He is now married with two children and a dog. He plans to travel to Mexico for vacation soon. His labs show that he is hepatitis A immunoglobulin G (IgG) negative, hepatitis B surface antibody positive, and varicella IgG negative. Which vaccination should not be given? Tetanus-diphtheria Hepatitis A Varicella Pneumococcal
Varicella
Rx: HIV+ patient exposed to chicken pox or shingles?
Varicella-zoster immune globulin.
A 32-year-old teacher with HIV and a CD4 count of 320/mm3 presents with a complaint of feeling like he has the flu. He notes 2 days of fever, cough, mild shortness of breath, and myalgias. He is currently on an antiretroviral regimen of zidovudine, lamivudine, abacavir, and efavirenz, initiated 3 weeks ago for a high viral load and declining CD4 count. He reports that he has been trying to take his medications but feels worse after taking them. On examination, his temperature is 39.3°C, his lungs are clear to auscultation, and he has mild diffuse abdominal pain and a faint maculopapular rash over his chest. Laboratory data show a white blood cell (WBC) count of 3200/μL, hematocrit of 32%, and platelet count of 124/mm3. Chest roentgenogram does not show any infiltrates. What is the best course of treatment? Neuraminidase inhibitor Trimethoprim-sulfamethoxazole Fluoroquinolone Modify antiretroviral therapy Symptomatic management
This patient has abacavir hypersensitivity syndrome, which occurs in approximately 3% to 5% of patients in the first 6 weeks. This syndrome is characterized by a fever (usually 39°C to 40°C), skin rash (maculopapular or urticarial), fatigue, malaise, GI symptoms (nausea, vomiting, diarrhea, abdominal pain), arthralgias, cough, and/or dyspnea. Continuation of the drug or rechallenge can be life threatening.
A 35-year-old patient presents to you with abdominal pain and fever 3 weeks after starting antiretroviral therapy. Her CD4 count has risen from 24 to 158/mm3; her viral load has declined from 240,000 to 100 copies/mL. You order an abdominal computed tomography scan, which shows enlarged periaortic and perihepatic lymph nodes and hepatomegaly. A subsequent liver biopsy shows abundant granulomata, but no organisms. The most likely explanation is Immune reconstitution syndrome Adverse drug reaction Lymphoma Newly acquired viral hepatitis Noncompliance with medications
Immune reconstitution syndrome is an atypical inflammatory reaction due to immune recovery 1 to 12 weeks after starting ART Starting antiretroviral therapy has now allowed the patient to mount an inflammatory response—probably to a previously subclinical opportunistic infection (perhaps Mycobacterium avium infection).
A patient presents to your practice for a health prevention visit. She is a 28-year-old sexually active woman with one male partner. She reports consistent condom use. According to the current Centers for Disease Control and Prevention (CDC) recommendations for HIV testing, which of the following statements best describes when HIV testing should be offered? She should be offered routine HIV testing now because of her age She is not a candidate for routine HIV testing because she is at low risk for HIV infection She should be offered routine HIV testing once she starts to contemplate pregnancy She does not require HIV testing because the prevalence of HIV in her community is unknown
The CDC recommends one-time voluntary routine screening of all Americans ages 13 to 64, Persons at high risk should be rescreened annually. Women should receive HIV testing as part of routine prenatal testing and should have repeat testing during the third trimester in high-risk areas. Although routine testing is not recommended in locations with a prevalence below 0.1%, locations with unknown prevalence should initiate screening in their residents.
A 32-year-old man who has sex with other men asks about “PrEP.” He has heard that taking daily tenofovir and emtricitabine will keep him from getting HIV. He has had receptive anal intercourse with three partners in the past month and only used condoms with one. Which of the following tests should be done prior to initiating pre-exposure prophylaxis (PrEP)? HIV enzyme-linked immunosorbent assay (ELISA) and Western blot HIV RNA polymerase chain reaction (PCR) Hepatitis B surface antigen Creatinine All of the above
Anyone considering PrEP for HIV should undergo HIV testing Given this patient’s recent risks, screen for acute HIV infection with a HIV RNA PCR or viral load Because tenofovir and emtricitabine are also active against hepatitis B, he should be screened for that as well. Tenofovir is contraindicated in patients with moderate renal insufficiency.
A 32-year-old man who has sex with other men asks about “PrEP.” He has heard that taking daily tenofovir and emtricitabine will keep him from getting HIV. He has had receptive anal intercourse with three partners in the past month and only used condoms with one. What would you advise him? He should see a psychiatrist for behavior modification He would be a candidate for pre-exposure prophylaxis (PrEP) and should also receive counseling about condom use He should be told condoms are more effective than PrEP and he should just use them consistently He should be told tenofovir gel has fewer systemic side effects and can be used with condom use
He would be a candidate for pre-exposure prophylaxis (PrEP) and should also receive counseling about condom use PrEP has been shown to reduce HIV transmission about 50% with consistent use in high-risk men who have sex with men (MSM). Consistent condom use is even more effective at preventing HIV transmission, but unfortunately is not regularly practiced in “real-world” settings. Tenofovir gel has been studied as a means to reduce male-to-female transmission, but its efficacy in reducing transmission among MSM has not yet been shown.
Chemoprophylaxis regimes and CD4 counts
> 200: none 200-50: Bactrim/dapsone/atovaquone < 50: + (azithromycin or clarithromycin) Explanation: Aerosolized pentamidine can be used for PJ prophylaxis also but NOT for Toxo
Which non-infectious conditions can occur when the CD4 is between 200 and 500?
CIN Lymphoma Anemia ITP
CMV-Esophagitis.OnDx
CD4 < 100; What else should be screened for?
CMV Retinitis
Ophthalmoscopy every 6 months till CD4 > 100
Any CMV infection in a HIV+ patient should prompt screening for CMV retinitis
Progressive dyspnea in well controlled HIV
Pulmonary hypertension
PJ Pneumonia
Rx
Bactrim + prednisone
DVT+major bleeding
Mx
IVC filter
temporary
a diffuse lung disease characterized by the accumulation of amorphous, periodic acid-Schiff (PAS)-positive lipoproteinaceous material in the distal air spaces. Rx
Pulmonary alveolar proteinosis (PAP)
Whole lung lavage —
For patients who have moderate-to-severe symptoms and hypoxemia, whole lung lavage (WLL) under general anesthesia via a double-lumen endotracheal tube is the most widely accepted and effective form of treatment.
Autoimmune
Bronchopulmonary sequestration
Section of lung which does not receive blood supply from the pulmonary artery
HAPE vs high altitude cerebral edema
Nifedepine vs acetazolamide: which drug for preventing HAPE?
Nifedepine
- No history of problems at high altitude, the risk of HAPE is low
Prophylaxis with nifedipine for individuals with a history of HAPE or with known predisposing factors who must ascend to altitudes above 2500 m without adequate time for acclimatization (Grade 2B). In such circumstances, we give nifedipine 30 mg of a slow release formulation every 12 hours.
Acute mountain sickness (AMS) and high altitude cerebral edema (HACE) are considered to represent two points along a single spectrum of disease, with the same underlying pathophysiology. Increased cerebral vascular permeability is a central feature that occurs through a number of mechanisms.
AMS is the most common high altitude illness (HAI). As with all HAI, incidence depends upon individual susceptibility, the elevation reached, and the rate of ascent. The epidemiology of AMS and HACE are discussed further in the text; general risk factors for HAI are discussed separately.
AMS is diagnosed clinically in a person who lives at low altitude but has recently ascended to high altitude (generally over 2000 m). Symptoms resemble those of an alcohol hangover: primarily headache often associated with fatigue, lightheadedness, anorexia, nausea and vomiting, disturbed sleep, and mild shortness of breath with exertion. Onset of AMS is usually delayed for 6 to 12 hours following arrival at high altitude, but can occur as rapidly as one to two hours or as late as 24 hours. (See ‘AMS diagnosis’ above.)
HACE generally occurs in individuals with AMS and/or high altitude pulmonary edema (HAPE) at elevations over 3000 to 3500 m. The hallmarks of HACE are encephalopathic symptoms and signs, including ataxic gait, severe lassitude, and progressive decline of mental function and consciousness (irritability, confusion, impaired mentation, drowsiness, stupor, and finally coma).
The onset of encephalopathy and ataxia signifies the transition from AMS to HACE and occurs unpredictably, requiring as long as three days or as little as 12 hours. (See ‘HACE diagnosis’ above.)
Treatment
●Treatment of AMS is based upon symptom severity. Mild illness can be managed conservatively (avoid ascent, limit activity) with symptomatic treatment (eg, analgesic, antiemetic); moderate to severe symptoms may require medication (eg, acetazolamide, dexamethasone), supplemental oxygen, and occasionally descent. In the field, portable hyperbaric therapy may helpful. It is important that group members and the afflicted individual remain alert for any symptoms or signs of worsening disease, particularly at elevations where AMS may rapidly progress to HACE (above 4000 m). The same general treatment approach is used for both children and adults. (See ‘AMS treatment’ above.)
