HIV Dan Flashcards
T/F
HIV is an enveloped single stranded DNA virus
False
enveloped single stranded RNA virus
T/F
HIV belongs to the genus Lentivirus within the family of Retroviridae
True
What is the incubation period for HIV?
3-6 weeks
but shorter when transmitted hematogenously and/or when large viral load
HIV uses the bodies own cells to replicate itself
True
RNA of virus turned into DNA by reverse transcriptase
viral DNA incorporated into human genome
transcription of viral DNA into RNA which either becomes the genome of new viral particles or is translated into viral proteins
T/F
HIV particularly affects CD+ T cells resulting in significant reduction in host immunity
True
cell-mediated rather than humoral immunity
T/F
HIV replication involves destruction of the host cell
True
results in decline in CD4+ count
T/F
In established HIV >1 million viral particles are produced in the host each day
False
> 1 billion
Which HIV linaage is most common in Australia?
Cade B of the M (Major) lineage - 3rd highest worldwide incidence
seen in UK, USA, Aus
Cade C has highest incidence - South Africa, India, China
2nd is Cade A - Africa, Eastern Europe
Other lineages are;
O - Outlier - Camaroon region
N - New - West Africa
T/F
HIV-2 is more transmissable than HIV (1)
False
less transmissable
T/F
HIV-2 is identical to HIV-1
False
Viral structure, mode of transmission, and immune deficiency syndrome is identical to those of HIV-1
But there are genetic differences and is less transmissable
What are the differences between HIV-2 from HIV-1?
5-8 fold less transmissibility rare vertical transmission longer period of latency slower rate of cD4+ count decline slower clinical progression
What are long-term non-progressor patients?
Those whose immune response is sufficient to keep the infection under control so that they do not develop AIDS
T/F
The decreased ability of infected helper T lymphocytes to proliferate and produce IL-2 is central to the pathogenesis of HIV infection
True
T/F
CD8+ cytotoxic T-lymphocyte response is an important factor in controlling HIV infection throughout the disease course
True
What is the definition of AIDS?
CD4+ count of less than 200 cells/mm3 and/or the presence of an AIDS-defining condition
T/F
The earliest cutaneous manifestation of HIV infection is an acute morbiliform exanthem that is often accompanied by fever an lymphadenopathy
True
seroconversion reaction
During this phase, HIV virus disseminates widely, seeding lymphoid organs and other internal sites such as CNS
What are AIDS-defining illnesses?
Mostly unusual infections and some rare cancers e.g Kaposi's sarcoma various lymphomas disseminated Coccidioidomycosis extrapulmonary Cryptococcosis Intestinal Cryptosporidiosis for >1 month Mucocutaneous HSV lasting >1 month M. TB of any type other dissemniated Mycobacterial infections Pneumocystis Jiroveci Pneumonia (PCP) Toxoplasmosis Non-typhoid salmonella
T/F
Median time for progression of untreated HIV to AIDS is 5 years
False
10 years
T/F
Rapid progressors develop AIDS within 2-3 years
True
T/F
Pts on modern ART (HAART) have a normal life expectency
True
T/F
gender and race do not affect rate of progression of HIV
True
T/F
MSM HIV pts progress more quickly than transfusion recipients
False
other way around
T/F
people who contract HIV when they are older progress more quickly than those who are younger
True
T/F
Pts with asymptomatic seroconversion progress more quickly
False
slower progression
T/F
50% of pts have asymptomatic seroconversion
False
10-25% asymptomatic
T/F
A single measurement of plasma RNA viral load early in infection is a powerful predictor of the subsequent risk of progression to AIDS and death
True
High viral load earlier is poor prognostic marker
also rapid decline in CD4+ count
T/F
Combined measurement of CD4+ counts and viral load is an extremely accurate method for assessing the prognosis of infected patients
True
T/F
first-line initial ART includes two nucleotide/nucleoside reverse transcriptase inhibitors and one non-nucleoside reverse transcriptase inhibitor
True
T/F Antiretroviral therapy (ART) is recommended for all HIV-infected individuals, irrespective of CD4 count, to reduce the risk of disease progression
True
this is new
old guideline is to start ART when CD4+ counts ≤500 cells/mm3 or certain conditions or comorbidities
T/F
When HIV replication is adequately suppressed (i.e. below 50 copies/ml plasma), evolution of viral resistance to antiretroviral drugs is minimal
True
T/F
ART results in reduced HPV and poxvirus infections and anal cancer
False
These are increased
probably due to patients surviving longer
T/F ART results in reduction of; • candidiasis • KS • Eosinophilic folliculitis • Opportunistic mycoses/mycobacterioses • Oral hairy leucoplakia
True
What is Immune reconstitution Inflammatory Syndrome (IRIS)?
Similar to Jarisch-Herxheimer or reversal or Rx rcn in Buruli ulcer Rx
due to immune reconstitution especially when CD4+ counts rise at least twofold from depressed levels
Exacerbations of clinical severity of infections, neoplasia, and inflammatory diseases
e.g. Herpes zoster, leprosy, disseminated MAC, CMV
Which cutaneous conditions can flare during IRIS?
Infections
• TB, leprosy, Mycobacterium avium complex (MAC) and other mycobacterium, HSV, VZV, HPV, Molluscum, Candida, Demodex, Mallassezia (e.g. folliculitis), Leishmaniasis
Inflammatory disorders
• Psoriasis, seborrheic dermatitis, eosinophilic folliculitis, acne vulgaris, rosacea, LE, AA, dyshidrotic eczema, sarcoidosis
Neoplasms
• KS, Non-Hodgkin lymphoma, Multiple eruptive dermatofibromas
T/F
Antiretrovirals are all CYP450 inhibitors
False
many are inducers
some are inhibitors
T/F
HIV +ve pts get more morbilliform drug eruptions
True
What is most common drug to cause a cutaneous reaction in HIV-infected patients?
Co-trimoxazole
= TMP-SMX, Bactrim, Septrin
leads to and exanthematous eruption and fever in 50-60% of HIV-infected patients treated IV typically 8-12 days after initiating therapy
Often taken for PCP prophylaxis or toxoplasmosis
T/F
Co-trimoxazole causes sutaneous reactions in HIV pts 20x more than the general population
False
10x more
T/F
Retinoid-like AEs are seen with nucleotide inhibitors
False
seen in protease inhibitors
Include;
desquamative chelitis and xerosis, paronychia, ingrown toenails, periungual pyogenic granuloma-like lesions, curly hair
what are the common inflammatory dermatoses seen in HIV?
Pruritus/xerosis/icthyosis Pruritic papular eruption Nodular prurigo Folliculitis Eosinophilic folliculitis Seborrheic dermatitis Psoriasis Drug eruptions
sometimes;
GA
PCT
Reiter’s
what are the common cutaneous infections seen in HIV?
HSV VZV Viral warts Mollusca Oral and vaginal candidiasis Tinea (including onychomycosis) Scabies
what are the common skin cancers seen in HIV?
BCC
SCC
Kaposi’s sarcoma
Eruptive atypical melanocytic nevi and melanoma
T/F
Kaposis sarcoma usually occurs in HIV pts with CD4+ count below 250 cells/mm3
False
Below 500 cells/mm3
T/F
Infection with mycobacteria and atypical fungi usually occur only when the CD4+ count is below 250 cells/mm3
True
Whic skin complaints are associated with the lowest CD4+ count range
Major apthae
Acquired ichthyosis
Papular pruritic eruption
Non-healing ulcers esp perianal due to HSV or CMV
Giant molllusca
Mycobacterium avium complex (MAC) infection
Aspergillosis
T/F
seb derm, vaginal candida and oral hairy leukoplakia can occur with high CD4+ counts, >500
True
What are the features of seroconversion
(Acute Retroviral Syndrome/Acute primary HIV infection/Exanthem of Primary HIV infection)?
Occurs 1-6 wks post infection
lasts about 2 wks in most pts
fever, lymphadenopathy, pharyngitis +
generalised morbilliform exanthem (in 75%) most prominent on face and torso and sparring the distal extremities and lasting 4-5 days
Can be arthralgia, myalgia, night sweats, lymphadenopathy, GI upset
rarely oral or genital ulcers, urticaria, EM, intertrigo or enanthem (eruption on mucous membranes)
T/F
The CD4+ count does not decline during seroconversion
False
declines a little then peaks but not to pre-infection levels before slowly declining over years
T/F
During seroconversion the CD8+ cells peak just after the peak viraemia and trough of CD4+ count
True
T/F
New HIV tests detect the viral protein HIV-1 p24 antigen which is detectable before antibodies appear
True
T/F
Pts can remain negative to traditional HIV Ab tests for up to 3 months after infection
True
T/F
Hyperpigmenattion of skin, nails and mucosae is common in HIV pts
True
Causes include;
drugs (idovudine, hydroxyurea, indinovir)
opportunistic infections such as toxoplasmosis
hypoadrenalism
T/F
HIV-related thrombocytopenic purpura may present and can be mistaken for KS
True
T/F
HIV-infected patients are low risk for venous and arterial thrombosis
False
increased risk
T/F
85% of HIV pts get seb derm
True
Most common skin disorder to affect HIV-infected individuals
seen in all stages of disease
more severe if lower CD+ count esp if
T/F
10-15% of geneal population get seb derm
False
1-3%
T/F
HIV pts at increased risk of seb derm erythroderma and pityrosporum folliculitis
True
In which seb derm pts should you check HIV test?
Sudden onset or acute worsening of seb derm should alert to possibility of HIV
esp if high risk social group
T/F
Atopic dermatitis is more common in children with HIV
False
T/F
HLA-Cw0602 is associated with psoriasis in HIV pts and with post strep guttate psoriasis
True
T/F
Psoriasis in HIV-infected patients may be florid, severe, of sudden onset and atypical
True
T/F
Psoriasis is more common in HIV pts
False
T/F
HIV pts are at higehr risk of Reiter’s syndrome and more severe features of it
True
may follow chlamydia inf or bacterial gastroenteritis
What are the features of Reiter’s/ reactive arhtritis?
SARA RUCA Sexually Acquired Reactive Arthritis Rash - mucocutaneous features Urethritis (non-gonococcal) Conjunctivits Arthritis mucocutaneous features; Oral ulcers scaly red patches/plaques resembling psoriasis keratoderma blennorrhagicum balanitis circinata (scaly/eroded rash on glans) papules and pustules on fingers and toes paronychia
What is keratoderma blennorrhagicum?
Feature of reactive arthitis
usually occurs 2 months after the arthritis
hard, tender papules, pustules, bullae or scaly plaques on soles of feet extending up shins - may appear purpuric
How is reactive arthritis/ Reiters treated?
Treat cause
other Rx same as psoriasis - same topicals, nbUVB and systemics
T/F
Eosinophilic folliculitis occurs at CD4+ cell counts of 250-300
True
Cause unknown
Presents as centripetal (face (85%) and trunk) eruption of pruritic, erythematous, perifollicular papules and pustules
What is the treatment of Immunosuppression-associated Eosinophilic folliculitis?
ARV/HAART NB: immune reconstitution exacerbations have been reported Phototherapy very affective TCS Topical tacrolimus Oral antihistamines Oral dapsone Oral itraconazole (for its antieosinophilic effect) Oral isotretinoin
T/F
Pruritic papular eruption of HIV is a sign of an advanced degree of immunosuppression and may often be first sign of HIV (occurring with CD4+ cell counts below 100-200) with severity of the rash inversely proportional to the CD4 count
True
T/F
Pruritic papular eruption of HIV resembles insect bite reactions clinically and histologically
True
Excoriated, erythematous, urticarial non-follicular papules
associated with eosinophilia and elevated IgE
secondary impetiginisation of excoriated lesions common
T/F
Staphylococcus aureus is the most common bacterial pathogen in HIV patients
True
T/F
MRSA is 20x more common in HIV pts
False
6x more common
What are the uncommon skin infections in HIV?
Botryomycosis - verrucous discharging lesion with fistulae etc - staph or pseudamonas
Bacillary angiomatosis (cat scratch disease)
Mycobacteria - esp if v low CD4+ count
syphylis - May present atypically in HIV, test all HIV pts for syphylis
atypical zoster inc disseminated disease
C
T/F
zoster is the commonest cutaneous manifestation of immune restoration syndrome
True
what is the presentation of skin CMV in HIV pts?
Purpura, papules, nodules, verrucous plaques and painful ulcers, including perineum and nodular prurigo
Rx
Prophylaxis and treatment with ARV/HAART
IV foscarnet, ganciclocir, and cidofovir
What is acquired epidermodysplasia verruciformis?
Rare presentation of HPV skin infection in HIV pts
widespread flat warts and pityriasis versicolor-like macules or seb-k like lesions
T/F
purpuric ‘thumbprints’ on the lower abdomen are a feature of atypical infection with leishmaniasis in HIV pts
False
in strongyloidiasis
T/F
scabies can be recalcitrant in HIV pts
True
may need several doses of ivermectin + topicals
T/F
Rosacea-like demodicosis may be more frequent in HIV-positive patients
True
In what situations should de-sensitization to co-trimoxazole not be considered?
In pts who have had rcns such as DRESS or SJS/TEN
T/F
The cross-reactivity between dapsone and co-trimoxazole is 20%
True
avoid dapsone in pts who have had severe rcns to co-trimoxazole
T/F
Kaposis sarcoma is a virally induced disease due to HHV8
True
Controversial whether KS represents neoplasia or hyperplasia of lymphatic/blood vasculature
What are the clinical variants of Kaposis’s sarcoma?
Chronic or classic KS
African endemic KS
KS due to iatrogenic immunosuppression
AIDS-related epidemic KS
What are the features of classic KS?
Jewish (Ashkenazi) descent and/or of Mediterranean/Eastern European descent
age over 50, M>F
growing pink to red-violet macules on distal legs that may coalesce to form large plaques or develop into nodules or polypoid tumours
early lesions may regress while new lesions arise
Can involve mouth and GIT which may be asymptomatic
What are the features of African endemic KS?
Affects black Africans, M>F
4 subtypes;
• Nodular – resembles classic KS in course and appearance
• Florid – more biologically aggressive
• Infiltrative - more biologically aggressive
• Lymphadenopathic – predominantly affects children, primary tumours involve LNs (although skin and mucosal lesions may also be present) course is fulminant and fatal
What are the features of iatrogenic immunosuppression KS?
Due to meds e.g. pred, calcineurin inhibitors etc
M>F
clinically similar to classic disease
can be aggressive
often resolves if immunosuppression stopped
What are the features of AIDS-related KS?
Mainly affects MSM
Affects up to 40% of men who have AIDS and became HIV-infected via homosexual contact
Only 5% of other HIV/AIDS pts
Onset usually when CD4+ cell counts
what are the main histological features of Kaposis sarcoma?
Blue Spindle cell tumour with many RBCs in between
Spindle-shaped endothelial cells infiltrate through collagen forming slit-like spaces esp at periphery of lesion
Arranged in fascicles resembling schools of fish or storiform arrangement
Promontory sign is newly formed vessels protruding into an existing space
Only slight pleomorphism and sparse mitoses
May be plasma cells and some lymphocytes
Do HHV8 also +ve for CD31 and CD34
What are poor prognsotic factors in AIDS-associated KS?
Tumour (T) - Tumour-associated oedema or ulceration - Extensive oral KS - GIT KS - KS in other non-nodal viscera Immune status (I) - CD4+ count
How is AIDS-associated KS managed?
AIDS-defining illness initiation of ART/HAART recommended Local treatment (for localised disease): • Cryotherapy • Radiotherapy • Topical antivirals: cidofovir • Surgery (excision, C+C) • Laser • Intra-lesional IFN-alpha, TNF-alpha, vincristine • PDT • Cosmetic camouflage Systemic treatment • ART/HAART • Isotretinoin • Cidofovir • IV chemotherapy
T/F
skin malignancies constitute the most frequent non-AIDS defining cancers amongst HIV-positive people
True
T/F
HIV patients have a 3-5 fold risk of NMSC
True
T/F
HIV patients get more SCCs than BCCs usually
False
7x more BCCs than SCC
T/F
HIV patients get NMSC at a younger age
True
T/F
HIV patients get NMSC primarily on the head and neck
False
more often multifocal and located on trunk and extremities
T/F
Cutaneous SCC in HIV pts have a high risk of recurrence and metastasis
True
T/F
BCC in HIV pts have a high risk of recurrence and metastasis
False
no more than in other pts
T/F
HPV infection increases the risk of anogenital, oral, digital, and HPV-associated cutaneous SCCs in HIV-infected patients
True
aggressive treatment is often required to prevent recurrences and metastases
T/F
Melanoma in HIV pts behaves the same as in other cases
False
Melanoma may present atypically and behave more aggressively
What modifications should be made when manageing skin cancers in HIV +ve pts?
Special attention to local excisional margin control
More extensive investigation for regional or disseminated disease
Closer follow-up in patients with SCC and melanoma
T/F
HIV–associated lymphomas are most often non-Hodgkin B-cell type and high or intermediate grade
True
But can be B- or T-cell lineage
T/F
HIV–associated lymphomas most often develop when CD4+ cell counts
True
T/F
nearly all non-Hodgkin Lymphomas in HIV-infected patients are associated with EBV infection
False
50%
T/F
HIV pts are at increased risk of adult T-cell leukaemia and lymphoma caused by HTLV-1
True
T/F
Nail changes are common in HIV pts
True
up to 70% of pts
T/F
In HIV onychomycosis is usually due to T. rubrum or uncommon Candida species
True
What are the common oropharyngeal complications of HIV?
Xerostomia is common
Transient intraoral redness, erosions, and ulcers
Distressing mouth ulceration occurs frequently
Oral candida very common
Severe periodontal disease is not unusual
Hairy leukoplakia
Smoking and alcohol ingestion contribute
T/F
Oral Hairy leukoplakia has only emerged with the recognition of HIV
True
T/F
Oral Hairy leukoplakia is a sign of significant reduced immunity (low CD+ count)
False
early specific sign of HIV infection
Can occur with CD4+ count >500
T/F
Oral Hairy leukoplakia portends a poor prognosis as most pts go on to develop AIDS within 3 years
True
75% of patients develop AIDS within 2-3 years
T/F
Oral Hairy leukoplakia is painfull
False
asymptomatic and often unnoticed
T/F
Oral Hairy leukoplakia is thought to be associated with HPV infection
True
What is the Rx of Oral Hairy leukoplakia?
responds to ART/HAART topical podophyloin topical retinoids topical gentian violet cryotherapy surgical excision
