HIV/AIDS & Opportunistic Infection (Tyler)

Question 1

What is the highest risk of transmission for HIV?

Answer 1

Receptive anal intercourse (1:100 to 1:30)

Question 2

What is the next highest risk of transmission after receptive anal intercourse?

Answer 2

Needlestick with infected blood (1:300)
Sharing needles with drug usage (1:150)

***Why you need to be careful if collecting blood from HIV+ patient!

Question 3

What population are the most likely to be diagnosed with HIV?

Answer 3

African American Gay/Bisexual Males followed by Latino Gay/Bisexual Males

Question 4

Globally, what part of the population has the majority of new HIV infections been a part of (as of 2015)?

Answer 4

General Population (56%)

Question 5

This part of the world bears the heaviest burden of HIV and AIDS worldwide, accounting for 66% of all new HIV infections.

Answer 5

Sub-Saharan Africa

Question 6

Many individuals with HIV infection remain asymptomatic for years even without antiretroviral treatment. There is a mean time of approximately ________ between infection and development of AIDS.

Answer 6

10 years

Question 7

T/F. HIV has one specific symptom that makes it stand out right away.

Answer 7

False. A combination of complaints is more suggestive of HIV infection than any one symptom.

Question 8

Abnormal findings on PE range from completely nonspecific to highly specific for HIV infection. Those that are specific include…

Answer 8

• • Hairy leukoplakia of the tongue
• • Disseminated Kaposi sarcoma
• • Cutaneous bacillary angiomatosis

Question 9

For testing, the HIV test combines immunoassay for HIV antibody with a test for HIV ______ antigen. This improves the ability of the test to detect early HIV infection because ______ antigen becomes detectable a week before Ab in acute infection.

Answer 9

p24

p24

Question 10

A positive result on HIV-1/2 Ag/Ab combination assay is followed by testing of the sample with…

Answer 10

HIV-1/2 Ab differentiation immunoassay

Question 11

In the HIV-1/2 Ab differentiation immunoassay, if there is detection of HIV-1/2 Ab then the diagnosis is confirmed. If the samples are negative on Ab differentiation then they are tested with…

Answer 11

HIV-1 Nucleic Acid Amplification Test (NAAT)

Question 12

If NAAT result is positive with a negative Ab differentiation test, then what is the diagnosis?

Answer 12

Acute HIV

Question 13

If specimens are positive on initial combination assay and then are negative on Ab differentiation immunoassay and NAAT, the test is…

Answer 13

False-Positive

Question 14

Study the HIV testing paths on slides 18-19!

Answer 14

Know them, cuz Dr. Daddy Bob said so ;)

Question 15

This particular count is the most widely used marker to provide prognostic information and to guide therapy decisions.

Answer 15

CD4 Lymphocyte Count

***The trend is more important than a single determination!

Question 16

If the CD4 Lymphocyte count is >300, what should we consider?

Answer 16

• • Pneumococcal pneumonia
• • Pulmonary tuberculosis
• • Herpes Zoster
• • Oral candidiasis
• • Vaginal candidiasis
• • Fatigue

Question 17

If the CD4 Lymphocyte count is <300, what should we consider?

Answer 17

• • Oral Hairy Leukoplakia
• • Thrush
• • Fever
• • Weight Loss
• • Diarrhea

Question 18

If the CD4 Lymphocyte count is <200, what should we consider?

Answer 18

• • Pneumocystis jirovecii pneumonia
• • Disseminated histoplasmosis
• • Kaposi Sarcoma
• • Extrapulmonary/miliary TB
• • Non-Hodgkin’s Lymphoma
• • CNS Lymphoma

Question 19

If the CD4 Lymphocyte count is <100, what should we consider?

Answer 19

• • Cryptococcosis (Cryptococcal meningitis)
• • Esophageal candidiasis
• • Toxoplasmosis

Question 20

If the CD4 Lymphocyte count is <50, what should we consider?

Answer 20

• • Mycobacterium-avium complex (MAC)
• • Cytomegalovirus (CMV)
• • Primary CNS lymphoma

***Know these for sure!!!

Question 21

Why should CD4 counts be monitored every 3-6 months in patients taking antiretroviral treatments consistently?

Answer 21

It measures the immune dysfunction

Question 22

CD4 counts do NOT provide a measure of how actively HIV is replicating in the body. Instead, what test is used to assess the level of viral replication and provide useful prognostic information that is independent of the information provided by CD4 counts?

Answer 22

HIV Viral Load test

Question 23

What is the AIDS-defining illness?

Answer 23

Opportunistic infections

• **Includes:
• • Multiple, or recurrent, bacterial infections
• • Pneumocystis jirovecii pneumonia
• • Kaposi Sarcoma
• • Lymphoma
• • CMV infection
• • Histoplasmosis
• • Coccidioidomycosis, disseminated or extrapulmonary
• • Cryptococcosis, extrapulmonary
• • Mycobacterium tuberculosis of any site

Question 24

This is the most common opportunistic infection associated with AIDS.

Answer 24

Pneumocystis jirovecii

Question 25

What is the cornerstone of diagnosis for Pneumocystis jirovecii pneumonia, which most characteristically shows diffuse or perihilar infiltrates (66%)?

Answer 25

Chest Radiograph

Question 26

A definitive diagnosis for Pneumocystis can be obtained in 50-80% of cases by what tests?

Answer 26

Wright-Giemsa Stain OR Direct Fluorescence Antibody (DFA) test of induced sputum

Question 27

When a sputum examination comes back negative, but the patient is still suspected of having Pneumocystis pneumonia, then what technique is used (95% accuracy in diagnosis)?

Answer 27

Bronchoalveolar lavage (BAL)

Question 28

Elevation of _______ _______ ________ occurs in 95% of cases of Pneumocystis pneumonia, but the specificity of this finding is at best 75%. A _______ _______ _______ test is more sensitive and specific for Pneumocystis pneumonia but it's still not used very much (usually can diagnose without it).

Answer 28

Serum Lactate Dehydrogenase (LDH) | Serum Beta-Glucan

Question 29

A normal diffusing capacity of carbon monoxide or a high-resolution CT scan of the chest that demonstrates no interstitial lung disease makes the diagnosis of ________ _______ VERY unlikely.

Answer 29

Pneumocystis pneumonia

Question 30

CD4 counts greater than ________ within 2 months prior to evaluation of respiratory symptoms makes a diagnosis of Pneumocystis pneumonia unlikely. Only 1-5% of cases occur above this CD4 count.

Answer 30

250 cells/mcL

Question 31

__________ can be seen in HIV-infected patients with a history of Pneumocystis pneumonia. This can be due to _________, which are cystic-appearing areas (on x-ray).

Answer 31

Pneumothoraces | Pneumatoceles

Question 32

What is the most common cause of pulmonary disease in HIV-infected persons?

Answer 32

Community-acquired pneumonia * **Can be from: - - Bacterial, mycobacterial, and viral pneumonias - - Recurrent: AIDS defining (as is the case with any recurrent bacterial process)

Question 33

This is the most common space-occupying lesion in HIV, causing multiple subcortical lesions with a predilection for the basal ganglia.

Answer 33

Toxoplasmosis

Question 34

Toxoplasmosis is a common cause of ________ ________ in patients with AIDS.

Answer 34

Focal Encephalitis

Question 35

Serologic tests are not useful for Toxoplasmosis, because Abs are prevalent in the general population. The presence of Abs in the ________ is helpful, although there is a high rate of false-negative results.

Answer 35

CSF

Question 36

_______ is more sensitive than contrast-enhanced CT scan in detecting toxoplasmosis. Imaging typically shows multiple ring-enhancing lesions with surrounding areas of _______.

Answer 36

MRI | Edema

Question 37

This is the 2nd most common cause of space-occupying lesions in HIV. It is typically a single ring-enhancing lesion, but can be multiple.

Answer 37

Primary CNS Lymphoma

Question 38

Primary CNS Lymphoma can develop into what? And what is it highly associated with?

Answer 38

Diffuse, Large-Cell, B-Cell Malignancy | EBV (CSF PCR)

Question 39

What does Primary CNS Lymphoma present with?

Answer 39

- - Mass lesion - - Headaches - - Confusion, disorientation - - Altered gait and balance, falls - - Focal deficits - - Seizures - - Onset days-weeks

Question 40

This can be a cause of considerable morbidity in severely immunocompromised HIV-infected individuals.

Answer 40

Cytomegalovirus (CMV)

Question 41

What is the most major problem encountered with CMV?

Answer 41

Retinitis -- looks like "cottage cheese and ketchup" infiltrates

Question 42

Kaposi Sarcoma is a low-grade vascular tumor associated with _______. Incidence of Kaposi Sarcoma in HIV-infected persons has significantly declined thanks to ________.

Answer 42

HHV-8 (Human Herpesvirus 8) | HAART (Highly Active Antiretroviral Therapy)

Question 43

Extracutaneous spread of Kaposi Sarcoma is common, particularly to the oral cavity, GI tract, and respiratory tract. Skin lesions appear most often on the...

Answer 43

- - LE - - Face (especially the nose) - - Oral mucosa - - Genitalia

Question 44

In what situations do we need to be prophylactic for Pneumocystis jirovecii and give medications?

Answer 44

- - CD4+ T cell count <200 - - Oropharyngeal candidiasis - - Prior bout of PCP (Pneumocystis Pneumonia) ***Needs to be one of above, not all 3!

Question 45

What medication is given for Pneumocystis jirovecii prophylaxis?

Answer 45

Trimethoprim-sulfamethoxazole (TMP-SMX) -- aka Bactrim ***1 DS tablet daily PO**