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Clin Med I > HIV and opportunistic infections > Flashcards

HIV and opportunistic infections Flashcards

1
Q

who gets opportunistic infections

A
  • immunodeficient
  • chemo pts
  • chronic steroid use
  • elderly
  • transplant pts
  • generally associated with T cell immunosuppression
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2
Q

what are the common fungal opportunistic infections

A
  • cryptococcus
  • histoplasma
  • candida
  • pneumocystis
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3
Q

what are the common viral opportunistic infections

A
  • CMV
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4
Q

what are the common parasitic opportunistic infections

A
  • toxoplasma
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5
Q

risk factors for fungal opportunistic infections

A
  • severity of T cell mediated immunity
  • recent or current use of antifungals
  • risk of exposure
  • neutropenia
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6
Q

how is cryptococcus transmitted

A
  • air droplets and bird droppings
  • spores inhaled -> lodged into lung alveoli -> dissemination -> infection
  • is a fungus
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7
Q

clinical manifestations of cryptococcus

A
  • meningitis*
  • insidious onset
  • altered mental status* - usually irritable
  • papilledema*
  • malaise, fever
  • n/v
  • fullness in ears
  • CT will be normal
  • opening pressure during LP will be very high
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8
Q

diagnosis of cryptococcus

A
  • test for antigen in CSF
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9
Q

treatment of cryptococcus

A
  • amphotericin B

- fluconazole*

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10
Q

how is histoplasmosis transmitted

A
  • inhalation
  • exposure to chicken coops
  • endemic to certain parts of US
  • is a fungus
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11
Q

clinical manifestations of histoplasmosis

A
  • 1-3 mo after exposure
  • fever
  • weight loss*
  • dyspnea on exertion
  • skin ulcers*
  • hepatosplenomegaly
  • lymphadenopathy
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12
Q

diagnosis of histoplasmosis

A
  • urine test

- h. capsulatium antigen sensitivity in urine

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13
Q

treatment of histoplasmosis

A
  • amphotericin b

- itraconazole*

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14
Q

what are the CD4 counts where candidiasis infections occur

A
  • < 300

- esophagitis may also occur when <100

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15
Q

what is the most common cause of dysphagia and odynophagia in AIDS pts

A
  • candidiasis

- is a fungus

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16
Q

treatment for candidiasis

A
  • fluconazole*

- avoid topical treatments d/t low cure rate and high relapse rate

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17
Q

diagnosis

A
  • gold standard= EGD endoscopy
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18
Q

clinical manifestations of candidiasis

A
  • burning/ stabbing in mouth and/or throat
  • white markings with surrounding erythema
  • raised tissue
  • not uncommon to have candidiasis, herpes, and CMV co-infection
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19
Q

how is pneumocystis jirovecii transmitted

A
  • attach to alveolar epithelium -> inflammation, interstitial edema, diffuse alveolar damage
  • enviornmental exposure is main cause
  • fungus with tropism for lungs
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20
Q

clinical presentation of pneumocystis jirovecii

A
  • gradual onset
  • fever
  • dry cough
  • dyspnea
  • average 1 month before medical consut
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21
Q

diagnosis of pneumocystis jirovecii

A
  • imaging- HRCT chest

- lab- BAL immunoflorescence

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22
Q

treatment of pneumocystis jirovecii

A
  • bactrim
  • either IV or PO X 21 days
  • steroids
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23
Q

at what CD4 level does CMV infection occur?

A
  • <50
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24
Q

CMV clinical manifestations

A
  • mainly affects retina
  • no pain
  • floaters, blurred vision, decreased peripheral vision
  • light flashes
  • sudden vision loss
  • starts in 1 eye but usually involves both
  • blindness d/t retinal detachment
  • *** any acute vision loss, young, and immunosuppressed is CMV until proven otherwise
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25
diagnosis of CMV
- perivascular fluffy yellow-white retinal infiltrate +/- hemorrhage
26
treatment of CMV
- IV ganciclovir
27
at what CD4 count does toxoplasmosis infection occur?
- CD4 <100 has 30% risk without ppx | - CD4 < 50 has 75% annual risk without ppx
28
what causes toxoplasmosis
- t. gondii | - 30% of people in US are seropositive
29
clinical manifestations of toxoplasmosis
- HA - confusion - fever - lethargy - seizures - altered mental status - psychomotor retardation - may mimic lymphoma
30
diagnosis of toxoplasmosis
- IgG serology for t. gondii - order MRI - LP for malignant cells and EBV, order PCR for t. gondii - brain biopsy if no clinical or radiological improvement after 2 weeks tx
31
treatment of toxoplasmosis
- pyrimethamine + sulfadiazine + leucovorin
32
how the HIV virus works
1*. attaches to host cell via CD4 cells and coreceptors 2. fusion, RNA virus sends out genetic material 3*. reverse transcriptase makes RNA into DNA 4*. DNA is integrated into host DNA via integrase 5. DNA -> RNA -> viral proteins 6*. new virus formed, protease assembles mature proteins *= target of drug therapy
33
stages of HIV infection
- early infection - clinical latency - AIDS
34
when do you diagnose someone with AIDS
- CD4 <200 | - dx with AIDS defining condition
35
general course of infection in untreated pt
- first few weeks VL is detectable (once it hits 50) - weeks 3-6 VL peaks then spontaneously drops - VERY contagious during peak - CD4 dips down during acute infections - over years CD4 drops and VL increases - 7-10 years in untreated pt until AIDS dx or death
36
what labs do you order when HIV is suspected
- VL - CD4 count - Hep B and C - Toxicology - STD tests - PPD - CMV - make sure vaccines are up to date
37
what are the parameters for positive PPD test
- health care worker- 10 mm - general population- 15 mm - HIV- 5 mm
38
who is at the highest risk for HIV infection
- MSM - heterosexual women - IVDU - minorities - ages 25-35 highest risk new dx - ages 35-44 second highest risk new dx
39
what are HIV transmission risk factors
- VL - lack of circumcision - sexual partners - sexual practice - STD- ulcers increase risk by 4X - genetics
40
what is the most risky sexual practice for HIV transmission
receptive anal intercourse
41
common sx of acute HIV infection
- fever - lymphadenopaty - pharyngitis - rash - myalgia/ arthralgia - HA - less commonly oral or genital ulcers, N/V/D
42
how do you screen for HIV?
- 4th gen Ag/Ab testing - pushes back theoretical time to pos to days 16 or 17 - MUST f/u with VL testing - VL ALWAYS high during acute infections
43
differential dx for primary HIV infection
- EBV (mono) - CMV - toxoplasmosis - rubella - syphilis - hepatitis - other viral infections
44
common conditions in early symptomatic HIV
- persistant vaginal candidiasis - oral hairy leukoplakia - shingles on more than one dermatome - cervical dysplasia or carcinoma
45
AIDS defining conditions
- candidiasis of bronich, trachea, lungs, esophagus - invasive cervical cancer - coccidiomycosis - cryptosporidiosis - CMV retinitis - encephalopathy - chronic herpes ulcers > 1 mo - histoplasmosis - kaposi sarcoma - lymphoma - mycobacterium - pneumocystis jirovecii - toxoplasmosis
46
HIV medication categories
- nRTIs (nucleoside reverse transcriptase inhibitors) - nnRIT - PI (protease inhibitor) - entry inhibitors - INSTIs (integrase strand transfer inhibitors)
47
HIV treatment considerations
- must be ready to start - tx everyone who is infected - consider dosing sched/ how many pills/ food - must include 3 active drugs to start - genotyping before start
48
nRTIs
- backbone of tx - all regimens have at least 2 of theses - all can cause metabolic acidosis- monitor bmp if someone is very sick after initiation - tenofovir - lamivudine - emtricitabine - abacavir - zidovudine
49
tenofovir
- new form= TALA - less toxicities - commonly used - nRTI
50
lamivudine
- low threshold to resistance | - nRTI
51
emtricitabine
- low threshold to resistance | - nRTI
52
abacavir
- HLA 5701 testing - if pos for HLA can cause cardiotoxicity - nRTI
53
zidovudine
- rarely used d/t metabolic ADRs - used during delivery - nRTI
54
efavirenz
- very effective - rash- will go away - vivid dreams - nnRTI
55
etravirine
- "salvage treatment" - effective vs. efavirenz resistant strains - nnRTI
56
rilpivirine
new nnRTI
57
doravarine
newest nnRTI
58
protease inhibitors
- not used bc very metabolically toxic | - usually need metabolic booster- ritonavir or cobicistat (DDI risk)
59
atazanavir
- can cause jaundice | - PI
60
darunavir
- resistant to many mutations | - PI
61
INSTIs
- very save, effective and well tolerated
62
raltegravir
- INSTI
63
elvitegravir
- only coformulated with cobicistat | - INSTI
64
dolutegravir
- most effective - high resistance barrier - BBW for use in pregnancy - neural tube defects - INSTI
65
pictegravir
- coformulated with metabolic booster | - INSTI
66
entry inhibitors
- maraviroc - blocks CCR5a receptor - test for tropism
67
recommended starting HIV regimens
- 2 nRTIs and INSTI - twho have boosted INSTI - preferred nRTI is TALA
68
alternative starting HIV regimens
- two NRTIs and one nnRTI - boosted PI plus two NRTI - two drug regimen if cannot use other drugs
69
what should happen to the VL after initiation of HIV tx?
- decrease 10 fold in first 2-4 weeks
70
what do you do if a pt is failing HIV regimen?
- check adherence- usually the cause | - persistent failure then should check genotype and phenotype while still on regimen

Clin Med I (16 decks)

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