HIV (CMV / EBV) Flashcards
What HIV virus is most common
HIV 1
RNA
What does HIV bind too
CD4 receptors present on T helper cells - most important
Also on monocytes / macrophage / neural
What type of virus is HIV
Retrovirus
What happens to HIV when inside CD4
Infects and destroys them so impairs immune
Reverse transcriptase makes DNA and incorporated into genome
Integrase integrates this to produce core viral proteins
Protease cleaves proteins
What is the natural Hx of HIV
CD4 declines
HIV viral load increases
What is normal CD4 level
> 500
If no symptoms = HIV infection
When does AIDS occur
CD4 <200
Takes about 7-8 years
Opportunistic infections
Increased risk of infection / tumour
How is HIV spread
Sexual - MSM / multiple partners
Blood - products, PWID, transplant
Vertical from mother to baby
Breast feeding
What is a seroconversion illness
When HIV Ab first develop 2-4 weeks post exposure
Viral load peaks
Very infectious in this time
Early Rx will reduce transmission and enhance immune recovery
Fever + rash think HIV and test
What are the symptoms of HIV seroconversion
Flu Fever Malaise Persistent generalised LN Maculopapular rash Toxic exanthema (rash) Headache Arthralgia Pharyngitis Mouth ulcer Liver dysfunction Diarrhoea Meningitis/ neuropathy = rare
When do you think HIV
EBV with -ve serology
How do you Dx
HIV Ab test = used in hospital
HIV PCR + p24 antigen
Antibodies might not be +Ve
How does stage 1 present
What must you exclude
Asymptomatic Persistent generalised lymphadenopathy Occurs when immune system has got more control Lasts a few years Exclude - TB - Infection - Malignancy
What are stage 2+3
HIV related illness where CD4 declining and viral load increasing
Not quite aids
How does stage 2 present
Weight loss <10% Minor mucocutaneous infection HZV = shingles HSV = herpes Recurrent upper tract infections
What are the symptoms of stage 3
Weight loss >10% Unexplained diarrhoea >1 month Unexplained fever >1 month Oral thrush (candidiasis) - can scrape off Oral hairy leukoplakia Pulmonary TB
Hepatitis HAND - HIV associated neurological disorder Peripheral neuropathy Increased MI risk Seborrheic dermatitis
Malignancy
- Kaposi sarcoma
- NHL
- Invasive cervical cancer
What is oral hairy leukoplakia
Can’t scrape off
EBV if immunocompromised
HIV defining so always test
What can cause diarrhoea
HIV enteritis itself Crptosporidium = most common and HIV defining so test - ZN stain CMV Mycobacterium avium Giardia
Is oral thrush common
Never in the young
What are symptoms of stage 4 CD4 <200
What are symptoms when CD4 <100
PCP Cerebral toxoplasmosis HIV dementia - Rx = ART TB - tuberculoma=. single enhancing lesion (not common) PML Kaposi Sarcoma HSV / CMV encephaliits Salmonella septicaemia HIV encephalopathy
<100 Oesophageal candidiasis - Diff from oral (pre-aids) Cryptococcal meningitis Primary CNS lymphoma Mycobacterium avium CMV retinitis Immune reconstitution inflammation syndrome - Opportunistic brain infection when started on ART
What is given as prophylaixis in patients with CD4 <200
PCP prophylaxis
Co-trimoxazole
How does it present and how do you treat PCP
SOBOE Dry cough Fever Pneumothorax \+Ve BAL with silver stain
Co-trimoxazole
Steroids if hypoxic as reduce resp failure
May need IV pentamidine if severe
How does mycobacterium avium
CD4 <50 Fever Abdominal pain Sweating Diarrhoea LFT LN HSM
How do you Dx and Rx
Blood - deranged LFT
Blood culture
Bone marrow
Rx = TB + Ax
How does Kaposi Sarcoma present
Purple papules / plaque on skin or mucosa of GI / respiratory tract
Haemoptysis
Pleural effusion
Commonly LN if children
What virus Kaposi
HHV-8
How do you treat Kaposi
ART
RT / chemo
Resection
How does toxoplasmosis present
Most common SOL Headache Confusion Drowsy Focal neuro Seizure Headache and vomiting if raised ICP Accounts for 50% of all CNS lesions
How do you Dx and Rx
CT shows single or multiple ring enhancing lesion with oedema
LP
Thalium spect = -ve
Rx
- Sulfafiazine
- Pyrimethanime
Ax
What causes CNS lymphoma
EBV
How do you Dx and Rx
CT shows single lesion
Thalium spect = +VE in contrast to toxoplasmosis
Steroid
Chemo
RT
Cerebral TB
Single ring enhancing lesion
When CD4 <500
Standard TB Rx
Less common
What viruses can cause neuro symptoms
CMV encephalitis - Oedematous brain - Rx = aciclovir HIV encephalitis HSV encephalitis Cryptococcus Meningiits
How does cryptococcosis meningitis present
Headache Fever Malaise N+V Seizure Focal neuro Meningitis
How do Dx and Rx
CSF India ink or cryptococcal antigen
CT shows menial enhancement
Repeat LP if raised ICP - high opening pressure
IV Anphotericin B
What is PML and what causes
How does it present
Widespread demyelination caused by JC virus
Presents like mini stroke / TIA
CT / MRI shows demyelination
Rx = ART
How does oesophageal candidiasis present
Dysphagia
Odynophagia
White patches which scrape of to be red
Never presents in children if no HIV
How do you Rx
Anti-fungal
What are RF for HIV
MSM PWID Other STI High prevalence country Sexual contact
When do you test for HIV
Anyone who requests
Universal screen - Ante-natal / TOP / prisoner / healthcare
At risk groups - IVDU
Anyone with hep B or C or TB
Indicator disease
All patients presenting where HIV is a differential
If high prevalence area
Indicator disease
PCP Viral hepatits Lymphoma TB Oral candida Oral hairy luekoplaia Cryptospiridium HAND All stage 3+ diseases
When could it be a differential but don’t always need to test
Unexplained weight loss
Diarrhoea
Difficult eczema
Pneumonia
How do you Dx HIV
Antigen and antibody test - HIV PCR and 24 antigen
ELISA
When do you test
4 weeks if lab
Can do POC but must be >3 months
Offer at 12 weeks if -ve
What is most accurate
HIV antibody
CDT / ELISA / western blood
What are other tests
HIV resistnace Mantoux Serology - CMV / HBV / syphillis Sub type Tropism Avidity - when developed
How do you monitor
HIV viral load
CD4 count
Drug levels for compliance
When do you start Rx
As soon as Dx
What is given as ART
3 drugs
2x NRTI + protease inhibitor
2x NRTI + NNRTI
What is a NRTI
AZT
Stop conversion to DNA
Why is it useful in pregnancy and dementia
Cross BB
What are SE of NRTI
GI Pancreatitis Hepatic Neuropathy Marrow toxicity Insomina Weight Kidney Risk of immune reconstitution inflammation syndrome when started
What are SE of NNRTI
Rash
GI
p450 inhibitor
What are SE of protease inhibitor
- end in navir
p450 inhibitor GI - Diarrhoea DM Hyperlipidaemia Lipodystrophy Jaundice and hepatitis
SE of integrated inhibitor
- end in gravir
Rash
GI
If viral load undetectable
Non-transmissible
What are challenges of HIV
Osteoporosis Cognitive Malignancy CVS disease TB Hepatitis B and C Renal disease DM Neuropathy
How do you prevent HIV
Condoms Circumcision PREP PEP Vertical transmission.- ART by 24 weeks gestation + C-section
What are chance of developing from percutaneous (needle stick) HBV, HCV, HIV
HBV = 30% HCV = 3% HIV = 0.3%
What are chance from mucotaneous (blood / body fluid)
HIV <0.1%
Transfusion = 100%
Mother to fetus = 50% but reduced with C-section + ART
What do you do if exposed
Wash Encourage bleed Report to OHS or A+E Risk assessment - type of injury - patient details Combination ART 28 days Vaccine against hep B / booster Test source - patient Stop PEP if source -ve If +Ve continue for 4 weeks Test in 12 weeks
What do you do if expose to HCV
No vaccine
No Ig or antiviral
Early treatment
Do monthly PCR and Rx
What do you do if exposed to HBV
Vaccine
Ig
What do you do to avoid
Hygiene Cover wounds Protective measure Protect mucous membrane Prevent puncture wounds Avoid sharps Safe disposal
What is given as PEP
3 ART for 28 days up to 72 hours after exposure
Test at 12 weeks
What do you do for PREP
2 ART
What do you do if on PREP
Monitor eGFR
What does CMV cause congenital
Growth retardation Petechiae Microcephaly Sensorineural deafness Encephalitis HSM
What does CMV monomucleosis cause
Glandular fever
Typical symptoms
What does CMV retinitis cause
Painless progressive visual loss in HIV+ve
Haemorrhage and exudate
Retinal haemorrhage
Necrosis on fundoscopy
How do you Dx and Rx
PCR of vitreous fluid
IV Anti-viral
What else does CMV cause
Encephalopathy
Pneumonitis
Colitis
What causes Mononucleosis
EBV
CMV
What is triad seen in 98%
Sore throat
Fever
Lymphadenopath
What are other symptoms
Malaise Fatigue Palatal petechiae Splenomegaly Hepatitis - ALT rise Lymphocytosis Haemolytic anaemia
How long to resolve
2-4 weeks
How do you Dx
FBC
Monospot
How do you treat
Rest
Fluid
Avoid alcohol
Simple analgesia
What should you avoid
Contact sport 8 weeks as predisposed to splenic rupture
Amox as maculopapular rash
What malignancy associated with EBV
Burkitt’s
Hodgkin’s
HIV central nervous lymphoma
Hairy leukoplakia in HIV
What must be given to test for HIV
Consent
What else do you do apart for ART if Dx with HIV
CVS disease - monitor RF + lipid
Yearly cervical smear in women
Co-trimox for PJP
Make sure vaccines are up to date
When do you test children for HIV
HIV +ve parent
Immunodeficeincy suspected
Sexually active if ask
RF e.g. needle stick / sexual abuse
How do you delivery baby if mother +Ve
Normal if viral load undetectable
C-section if not
IV anti-viral during delivery
What is given after birth
Prophylactic anti-viral to baby
Can you breastfeed
No
What are aids defining malignancy
Kaposi sarcoma
Cerebral lymphoma
NHL
If have HIV as a doctor
No hands in body cavity so no surgery
Regular CD4
If gets above a certain level then off work
What is target viral load
<200
