HIV/AIDS & OI's Flashcards
HIV/AIDS Overview
Path:
S/Sx:
Dx:
Tx:
HIV/AIDS Overview
Path:
- HIV attacks CD4 molecules on immune cells -> virus uses reverse transcriptase to fuse RNA with immune cell’s DNA -> replication -> leaves cell -> invades more immune cells via CD4
S/Sx:
- Acute Infection: nonspecific viral symptoms, fever malaise, painful mouth sores, rash, hepatosplenomegaly
- Chronic Infection: Asymptomatic, lymphadenopathy, CD4 depletion, disseminated zoster, thrombocytopenia, thrush, recurrent viral infxn, STIs, TB, recurrent MRSA pna
- Symptomatic Infection/Non-AIDS-Defining: Thrush, neruopathy, cervical dysplasia, fever, weight loss, anemia, recurrent herpes, ITP
- AIDS-Defining/Late-Stage: CD4 < 200; opportunistic infections; tumors; wasting; neuro complications
Dx:
- 4th Generation Antigen/Antibody Test: P24 antigen test + viral load
- Historical: ELISA and Western Blot
- NAT: Definitive viral load, expensive
Tx:
- Start ART regardless of CD4 count
- Need 95% adherence
- TRIPLE DRUG REGIMEN: always
- SEs: Diarrhea, nausea, fatigue, dizziness,, insomnia, HA, neuropathy, liver/kidney toxicity, osteoporosis
- Long Term SEs: Lipodystrophy, atrophy, hypertriglyceridemia, HLD
- DDIs: PPIs, OCP, St. John’s Wort
OI Prophylaxis for: PCP/PJP, Toxo, Histo, MAC, Crypto & CMV
CD4 Count:
Drug of choice:
PJP PPx
CD4 Count: <200
Drug of choice: Bactrim
Toxo PPx
CD4 Count: <100
DOC: Bactrim
Histo PPx
CD4: < 100
DOC: -azole antifungal
MAC PPx
CD4: <50
DOC: Azithromycin
Crypto & CMV
No PPx
OI: PML
Path:
S/Sx:
Dx:
Tx:
OI: PML
Path: Polyomavirus -> Widespread demyelination -> 5% in AIDS
S/Sx: Dysarthria, dysphasia, aphasia, ataxic gait, cognitive changes, oculomotor palsy
Dx:
- CSF: JCV present
- Brain MRI: Gad-enhancing white matter lesions
- Brain bx: Rare
- Dx of exclusion
Tx:
- AART therapy (Sx may initially worsen)
- PML should regress in roughly 12 months
OI: CMV Retinitis
Path:
S/Sx:
Dx:
Tx:
OI: CMV Retinitis
Path: CMV infxn -> inflammation of retina in 15-40% AIDS
S/Sx:
- Early: Asymptomatic, floaters, hazy vision, constitutional sx, pain/photophobia
- Late: Geographic scotoma (partial or total blindness)
Dx:
- PCR: CMV viremia
- CD4 < 50
- HIV RNA > 100k
Tx:
- IV Gancyclovir, foscarnet, cidofovir
- Oral: Valgancyclovir
- Surgery for retinal detachment
OI: Bacterial Diarrhea
Path:
S/Sx:
Dx:
Tx:
OI: Bacterial Diarrhea
Path:
- CD4 < 200 infected with E. Coli, campylobacter, salmonella, shigella
- CD4 < 50 infected with C. Diff
- AART itself can cause
S/Sx:
- Severe diarrhea +/- weight loss +/- bloody stool
- Fever or 6+ stools per day –> test stool
Dx:
- PCR Stool Culture (Biofire)
- Blood culture, but may lack sensitivity
- Endoscopy: if Colitis/Proctitis
Tx:
- Hydration
- Ciprofloxacin vs Ceftriaxone vs Cefotaxime
- Treat STI if present
- Do not use anti-motility agents, especially in C Diff
OI: Bacterial Respiratory Infection
Path:
S/Sx:
Dx:
PPx:
Tx:
OI: Bacterial Respiratory Infection
Path:
- Step pneumoniae & H Influenzae most common
- P aeruginosa, MSSA, MRSA possible
- Chlamydophilia, legionella, mycoplasma rare
S/Sx:
- CAP findings
- Increased risk for bacteremia and mortality
Dx:
- Wide DDx: TB, pneumoccocal PNA, recurrent PNA, candidiasis in broncho, trachea, and lungs, PCP, MAC, mycobacterial infection, herpes simplex, pneumonitis
- Consider Urine Antigen Test for Listeria and Strep Pna
PPx:
- Begin AART and give PPV13 Vax
- Give PSV23 Vax 8 weeks later and/or CD4 above 200
- Hand washing, no sick contacts
Tx:
- IV Beta Lactam (ceftriaxone, amp-sulbactam) AND Macrolide (azithro, clarithro)
- OR: IV respiratory FQ (levoflox, moxiflox)
- PsA: ADD anti-PsA Beta Lactam (pip-tazo, cefepime, ceftazidime) OR Aztreonam if PCN allergy
- MRSA: ADD Vanco
- Tailor after C/S
PCP (PJP)
Path:
Epi:
S/Sx:
Dx:
PPx:
Tx:
PCP (PJP)
Path: Pneumocystis carinii virus -> Pneumonia
Epi: 20-40% Mortality in AIDS
- Risks: CD4 < 3; Hx PCP, thrush, bacterial pna, weight loss; High HIV RNA load
S/Sx:
- Subacute dyspnea, fever, cough -> progressive -> worsens over days to weeks
- Diffuse rales, tachypnea, tachycardia
- Extrapulmonary dz rare but possible in any organ
Dx:
- Definitive: High Se and Sp
- Induced Sputum
- Bronchoscopy with Lavage and Monoclonal Antibody Test
- Biopsy (transbronchial vs open)
- Labs: PaO2 < 35; LDH > 500 (low Sp)
- CXR
- Early: Normal
- Typical: Diffuse BL symmetrical interstitial infiltrates with fine perihilar reticular changes
- Atypical: Nodules, assymetrical, pneumothorax
- CT Thin Slice: normal vs. ground glass opacities +/- pneumatoceles
- Gallium Scan: High Se, Low Sp
PPx:
- Pregnant women AND adolescents with CD4 < 200: Bactrim, dapsone, atovaquone
- When CD4 > 200 for 3 months -> stop PPx
Tx:
- First Line: TMP/SMX 15-20/80-100mg/kg/day IV split q6-8h
- If (+) G6PD Deficiency: Pentamidine 3-4mg/kg/day
- Adjunct if PaO2 < 70 on RA or AA gradient > 35
- Start prednisone within 72h, long taper over 21 days
- 40mg PO BID -> 40mg PO daily -> 20 mg PO daily
- Or, Methylprednisolone at 75% Prednisone dosing
- Start prednisone within 72h, long taper over 21 days
- Do NOT delay treatment for diagnosis if suspicion high
- Nebs are INEFFECTIVE
- Treatment failure = 4-8d without improvement
OI: IRIS
Path:
S/Sx:
Dx:
Tx:
OI: IRIS
Path: Start AART in naive patient OR change in regimen -> Viral Load drops with CD4 improvement -> sudden immune response -> significant inflammatory response
S/Sx: Fever, SOB, cough
Dx: CXR: worsening of previously improving film
Tx:
- Continue AART unless life threatening
- i.e. Neuro involvement (similar to meningitis) can lead to elevated ICP refractory to steroids
- If you do d/c AART, monitor closely for OIs
- Caution: IRIS can occur/recur after restarting AART
OI: Kaposi’s Sarcoma
Path:
S/Sx:
Dx:
Tx:
OI: Kaposi’s Sarcoma
Path: Herpes virus -> spindle cell cancer -> vascular lesions
S/Sx:
- Begins in skin and mouth
- Progresses to GI and Lungs
- When tracts confluence -> severe lymphedema
Dx: Clinical
Tx:
- Localized: Surgical vs. XRT
- Diffuse: Systemic therapy (chemo)
