HIV Complications II

Question 1

Signs and symptoms of HIV x Candidiasis infeciton for:

• oral infection
• oesophageal infection

Answer 1

Oral:
* Asymptomatic
* Taste perversion
* Oral discomfort
* Pharyngeal discomfort on swallowing
* Creamy white plaques which may be stripped off from surface of tissue (in contrast to OHL)
* Erythematous patches
* Angular chelitis

Oesophageal infection:
* Dysphagia
* Retrosternal pain on swallowing (odynophagia)
* Nausea
* Creamy white plaques on endoscopy

Question 2

Most common fungal infection of CNS associated with HIV is? [1]

WHich is the most common opportunistic infection in AIDS? [1]

Answer 2

Cryptococcus - CNS involvement

PCP - overall most common

Question 3

Describe the treatment for oral / oesphogeal candida infection from HIV:

Topical tx [2]
Systemic tx [3]

Answer 3

Topical antifungals:
* Topical Nystatin / Amphoterecin lozenges
* Micanazole gel

Systemic antifungals (severe disease)
* Fluconazole 50-100mg/day
* If resistant e.g. long term use of Fluconazole or CD4< 50:
* Itraconazole
* IV Amphoteracin

Question 4

A patient with HIV suffers a pathology which is suspected to have arisen from inhaling a pathogen from bird faeces. What is the name of the pathogen? [1]

Answer 4

Cryptococcus Neoformans (CN)

Question 5

Cryptococcus Neoformans (CN) can impact which body systems? [3]

Describe the symptoms associated with each system being affected [+]

Answer 5

Skin:
- Umbilicated papules and ulceration

Lungs:
- Cough
- SOB
- Fever

Meninges & Brain:
- Asymptomatic (10%)
- Headache (most common symptom)
- Fever
- Mental change

Question 6

Describe how would investigate and diagnose pulmonary cryptococcal infection (associated with HIV)

Answer 6

Chest X-Ray:
* Consolidation +/- cavitation,
* Interstitial infiltrates
* Effusions

Diagnosis:
- Bronchoalveolar lavage

Question 7

Describe how would investigate and diagnose cryptococcal meningitis (associated with HIV)

Answer 7

DIAGNOSIS :
Serum:
- Crytococcal Antigens (CrAg)

CSF:
- High pressure; low glucose
- Indian ink test positive
- CRAG
- culture +/- lymphocytes
- low glucose; high protein; high pressure

CT:
- meningeal enhancement
- cerebral oedema

Question 8

A patient is dx with cryptococcal infection. They have a stain perfomed which confirms the dx.

What is the type of stain used? [1]

Answer 8

Indian Ink

Question 9

Describe the treatment for cryptococcal infection in HIV ptx:

Drugs [3]
Length [1]

Answer 9

IV Amphotericin
+/- Flucytoscine if severe

Then oral Fluconazole

Treat for 6 weeks minimum the repeat LP after this 6 weeks

Question 10

Which medication can be given for CN prophylaxis in HIV patients? [1]

Answer 10

PROPHYLAXIS: Fluconazole 200-400mg/ day.

Question 11

When should patients receive PCP prophylaxis? [1]

Answer 11

CD4 count < 200/mm³ should receive PCP prophylaxis

Question 12

Describe the clinical manifestation of PCP x HIV infection [+]

Answer 12

Features
* Pyrexia
* +/- Chest signs
* O2 desaturation on exertion
* dyspnoea
* dry cough
* fever
* very few chest signs

Question 13

Describe how you dx PCP x HIV

Answer 13

Chest X-Ray:
* May be normal
* Bilateral infiltrates (bat wings)
* Atypical appearance - effusions, consolidation, cavitation
* Upper lobes only (Pentamidine nebuliser prophylaxis)

Bronchoalveolar lavage:
* Silver staining
* immunofluorescence
* PCR

Question 14

How do you treat PCP x HIV? [3]

If PCP pO2 < 10kpa? [2] (very severe infection)

Answer 14

TREATMENT:
* Co-trimoxazole 120mg/Kg in 3 divided doses/day
* IV Pentamidine
* Clindamycin and Primaquine

Severe infection:
* IV Methylprednisolone 40mg qds (5 -10 days)
* Oral Prednisolone 40mg bd

Question 15

What do you give for PCP prophylaxis for PLWHIV? [3]

Answer 15

PROPHYLAXIS:
* Co-trimoxazole 960mg x 3 / week
* Nebulised Pentamidine
* Dapsone

Question 16

Describe the clinical presentation of HIV x toxoplasma gondii (TG)

Answer 16

Fever
Confusion
Headache
Drowsiness
Focal neurological signs: Fits

Question 17

Describe the dx and mx of HIV x TG

Answer 17

DIAGNOSIS:

CT/ MRI:
* Ring enhancing lesions
* Classically multiple (but may be single lesions)
* Confirm diagnosis by response to treatment - repeat scan after 3-weeks.

Question 18

Which infective organism is most likely in this PLWHIV? [1]

Answer 18

Cerebral toxoplasmosis
- demonstrates multiple small peripherally enhancing nodules located predominantly in the basal ganglia as well as the central portions of the cerebellar hemispheres. Only a small amount of surrounding oedema is present.

Question 19

Describe the treatment for TG HIV [2]

Answer 19

TREATMENT:
Sulphadiazine (or Dapsone or Clindamycin) AND Pyramethamine

Change to oral when improved (total 6 weeks of treatment)

Question 20

Prophylaxis for HIV x TG? [2]

Answer 20

Dapsone + Pyramethamine

Question 21

HIV x brisk diarrhoeal illness = ? [1]

Answer 21

Cryptosporidium parvum

Question 22

Dx of HIV x Cryptosporidium parvum? [2]

Tx? [1]

Answer 22

DIAGNOSIS:
Ziehl-Neelson staining of stool - may need up to 10
Rectal biopsy

TREATMENT:
* Difficult to eradicate if CD4 < 200, ART
* Paromomycin

Question 23

Dx of Microsporidium species X HIV? [1]

Tx? [3]

Answer 23

Microsporidium species:
- immunofluorescent staining of stool

TREATMENT
* ART
* Albendazole
* High dose Erythromycin

Question 24

Dx of Isospora belli x HIV? [1]

Tx [1]

Answer 24

DIAGNOSIS:
* Stool analysis

TREATMENT:
* Co-trimoxazole

Question 25

Dx of Aspergillus fumigatus x HIV? [1]

Tx [2]

Answer 25

Symptoms:
Cough, fever, dyspnoea

DIAGNOSIS:
Chest X-Ray - may see cavitation Bronchoscopy

TREATMENT:
* Amphoteracin B
* Itraconazole

Question 26

Dx of HIV x Histoplasma capsulatum (Histoplasmosis) [4]

Answer 26

• Chest X-Ray: diffuse infiltrates
• Pancytopenia
• Fungal blood cultures
• Biopsies of affected tissue

Question 27

S&S of HIV x Histoplasma capsulatum (Histoplasmosis) [4]

Answer 27

SYMPTOMS:
* Fever
* Constitutional symptoms
* Respiratory disease.

SIGNS:
* Hepato-splenomegaly, enlarged lymph nodes, chest signs 10% rash (resembles folliculitis or molluscum)
* Neurological signs

Question 28

Tx for HIV x Histoplasma capsulatum OR Penicillium marneffei (Histoplasmosis) [2]

Answer 28

TREATMENT:
Itraconazole, Amphoteracin B

Question 29

Describe the difference in presentation in toxoplasmosis vs lymphoma presentation in people living with HIV [3]

Answer 29

Toxoplasmosis:
* Multiple lesions
* Ring or nodular enhancement
* Thallium SPECT negative

Lymphoma:
* Single lesion
* Solid (homogenous) enhancement
* Thallium SPECT positive