HIV Disease: Diagnosis and Management Flashcards
HIV modes of transmission similar to what disease?
What three modes?
Hepatitis B
- Sexual,
- parenteral, and
- vertical (perinatal)
What are the bodily fluids that HIV is transmitted through?
4
Blood products
Semen
Vaginal fluids
Breast Milk
What are the ways that HIV can be transmitted through sex?
- Intercourse (penile penetration into the vagina)
- Oral
- Anal
- Digital Sex
When can a mother spread HIV during pregnancy?
3
Before Birth
During Birth
Postpartum
(breast feeding)
What has a higher risk of infection with HIV: insertive or receptive?
receptive
Stage 1 Primary: when will symtpoms occur and what will they be like?
2
Are they infectious at this point?
- Short, flu-like illness occurs one to six weeks after infection
- could be no symtpoms at all
Yes
Stage 2:
Lasts for how long?
What are symtpoms like? 2
What are the HIV levels in the blood like?
What about HIV antibody levels?
Asymptomatic
- Lasts for an average of ten years
- stage is free from symptoms, may be swollen glands
- The level of HIV in the blood drops to very low levels
- HIV antibodies are detectable in the blood
HIV ANTIGENS TOO
Stage 3:
What are symptoms like?
What happens to the immune system?
What emerges at this stage?
2
Symptomatic
- The symptoms are mild
- The immune system deteriorates
- emergence of opportunistic infections and cancers
What kind of virus is HIV?
What is the mechanism of action?
4
retrovirus (RNA creates DNA instead of DNA creating RNA)
- Reverse transcription of the viral RNA genome into double stranded DNA occurs
- imported into cell nucleus and integrated into cellular DNA
- rapid viral replication!
- CD4 cells drop, CD8 tells kill all the HIV infected cells
WHat cells does HIV target?
3
affects
- CD4-Helper T cells!
- macrophages and
- dendritic cells (B cells)
Infections that are thought to early defining diseaase in the diagnosis of AIDS?
4
- Slim disease
- Esophagel candidiasis
- Aggressive Kaposi’s sarcoma
- Crypotococcal meningitis
What country has the largest infection rate of HIV?
What country has the fastest spreading HIV?
Spreading fastest in Asia
Largest infection rate is in Africa
Whats HAART?
highly active antiretroviral therapy
Following infection what happens to the T cells?
So what kind of defect is the most important in understanding the pathology of HIV?
they become nonfunctional
There is a qualitative defect in T-cells which overshadows the simple quantitative defect
Clinically, the syndromes of HIV are from one of 3 mechanisms. What are they?
3
- Immunodeficiency
- Autoimmunity
- Allergy/Hypersensitivity reaction
What syndromes do we see do to immunodeficiency in HIV? 3
- Spectrum of infections and neoplasms
- Very low incidence of certain infections seen in other causes of immudeficiency (listeriosis and aspergillosis)
- Higher incidence of other infections (Kaposi’s sarcoma)
What syndromes do we see due to autoimmunity in HIV?
2
- Lymphocytic infiltrate infiltrate of organs (lymphocytic interstitial pneumonitis)
- Autoantibody production (immunologic thrombocytopenia)
What syndromes do we see due to Allergy/Hypersensitivity reactions in HIV?
2
- Higher rates of allergic reactions to unknown allergens (eosinophilic pustular folliculitis)
- Increased rates of hypersensitivity to medications
HIV disease is a continuum, but will be crudely broken down into four phases:
Primary HIV Infection
Asymptomatic Infection
Symptomatic Infection
AIDS
Length and severity of each phase is dependant on what?
Therapies?
2
on host and virus
- Use of antiretroviral therapy
- Use of chemoprophylaxis for opportunistic infections
How long is each phase of HIV: Primary? Asymptomatic? Symptomatic? AIDS?
3-14 days
4-8 years
4-8 years
2-20 years
Primary infection is brief, mononucleosis type of illness.
What are its symptoms?
12
Fever Sweats Lethargy Malaise Myalgias Arthralgias Headaches Photophobia Diarrhea Sore throat Lymphadenopathy Truncal maculopapular rash
Onset of primary infection of HIV?
How long does it last?
What percent of pts have symtpoms of the primary infection?
Sudden onset
Lasts 3-14 days
50%
Most common neuro symptoms in primary HIV?
2
are headache and photophobia
Most commonly seen symptom in ALL HIV+ patients is what?
generalized lymphadenopathy
What is the longest of the four phases of HIV?
Whats the most variable of the four phases?
Asymptomatic Phase
secondary phase
In secondary HIV how do we test if they have HIV?
2
WHy is this?
Whats dangerous about this stage?
Where is the virus replicating the most in your body?
- Lack of overt evidence of HIV disease
- Only evidence is sero-positivity
- The virus is in the cells hiding. Can’t detect it
Patients can easily spread the disease without their knowledge
GI tract
How will HIV be spread before birth?
During?
After?
rupture/tear in placenta
placental tear and blood
Breast feeding
What stage do you have the highest risk of infection?
primary stage
Symptomatic Seropositivity Onset ushers in first physical evidence of what?
What is the main symptom we will see?
immune dysfuntion
Persistent generalized lymphadenopathy
What kind of fungal in symptomatic HIV?
5
Localized fungal infections
- Toes
- fingernails, and
- mouth
- Women with recalcitrant vaginal candidiasis or
- trichomonal infections
What is one of the most commonly missed signs of HIV but is very prevalent?
Oral hairy leukoplakia
Cutaneous manifestations of symptomatic HIV are?
6
Generalized/systemic symtpoms?
3
- widespread warts,
- molluscum,
- psoriasis, and
- seborrheic dermatitis,
- multidermatonal zoster (usually only is one)
- herpes simplex
- nights sweats
- weight loss
- diarrhea
Physical examination findings for AIDS pts are?
Bottom line: Any “AIDS defining illness” regardless of CD4 count AND other opportunistic infections is when the CD4 count is what?
Its is generally best to look at what for diagnosis?
normal (non-specific)
CD4 count is less than 500
AND opportunistic infection
Generally best to look at effects on systems
Systemic symtpoms of AIDS?3
Persistent fever without focal signs requires work-up?3
Weight loss is due to what?
Increased metabolic rate due to what?
What do we use to treat weight loss?2
Nausea?1
Fever, night sweats, and weight loss
Blood cultures
Chest X-Ray
Sinus imaging
generally muscle mass loss
the virus compounds the problem
Growth hormone and anabolic steroids are used to try to get weight back and marijuana is used for nausea (or Rx dronabinol)
What is the most common opportunistic infection seen in AIDS?
What is the most common cause of pulmonary disease in the HIV infected patient?
-From what?3
4% of pts get what pulmonary disease?
URI?
Non-infectious causes of lung disease?3
Pneumocystis pneumonia
CAP
-Bacterial, mycobacterial and viral
TB
chronic and acute sinusitis
Kaposi’s, non-Hodgkins lymphoma, interstitial pneumonitis
Most common space occupying lesion in HIV?
Symtpoms? 4
Diagnosis? 2
Toxoplasmosis
- Headache,
- focal neuro deficits,
- seizures,
- altered mental status
Diagnosis by CT or MRI
Second most common space occupying lesion in HIV?
What imaging should we do to diagnose? 2
CNS Lymphoma
Imaging may be able to differentiate
May need brain biopsy
What is a diagnosis of exclusion based on brain imaging and CSF evaluation with symtpoms of cognitive skills and dimished motor speed for HIV pts?
AIDS Dementia Complex
How would we diagnose cryptococcal meningitis in HIV pts?
2
- Fever and headache with less than 20% having meningismus
2. positive latex agglutination of CSF and serum
Diagnosis of Leg weakness and incontinence due to spinal cord impairment
in HIV pts?
What will be seen on physical exam? 2
It is a diagnosis of exclusion so what should be ordered?
2
HIV myelopathy
Spastic paresis and ataxia
LP and MRI
Viral infection of the white matter of the brain in HIV pts?
Three symptoms of this diagnosis?
3
Progressive Multifocal Leukoencephalopathy (PML)
- Aphasia,
- hemiparesis, and
- cortical blindness
Peripheral Nervous System
diseases in AIDS?
- Inflammatory Demyelinating Polyneuropathy
Similar to Guillian-Barre’ - Transverse myelitis due to herpes zoster or CMV
- Peripheral neuropathy common in many HIV patients
- CMV can cause an ascending polyradiculopathy
What can peripherial neuropthy be caused by in AIDS?
2
From the disease itself or
May be drug induced due to some HAART drugs
CMV can cause an ascending polyradiculopathy. What is this?
2
- Lower extremity weakness
2. Neutrophilic ploeocytosis in CSF with negative bacterial cultures
Rheumatologic Manifestations
of AIDS?
3
Arthritis
Several inflammatory syndromes
Avascular necrosis of femoral head
What the most common joints that experience arthritis in AIDS?
Large joints
Several inflammatory syndromes that have been reported with AIDS?
4
Reiter’s syndrome
Psoriatic arthritis
SICCA syndrome
Systemic lupus erythmatosis
Complaints of what must be evaluated immediately in a HIV+ patient?
Why?
Why must it be attended to right away?
visual changes
CMV retinitis
rapidly progressing
What are the signs of CMV retinitis?
3
Perivascular hemorrhages and white fluffy exudates
owl eye
What else is common of the eye?
3
Herpes infection is also common
Toxoplasmosis is frequently recurrent
What is a very common GI issue with HIV?
What may it be directly due to?
How will the pt present?
2
How do we diagnose it?
2
If repeat stool studies are negaitve what is indicated?
If symptoms for > 1 month and no identifiable cause, presumptive for what?
Enterocolitis
HIV macrophage infection
May present with high fever and severe abdominal pain
Need repeat stool cultures and stool for ova and parasites
endoscopy
AIDS enteropathy
Secondary causes include what?
3
- bacteria
- viruses
- potozoans
Campylobacter, Salmonella, Shigella, CMV, adenovirus, Crytptosporidium, Entamoeba histolytica, Giardia, Isopora, Microsporidia
Skin Manifestations
of AIDS?
3
Herpes Simplex Virus (HSV) Infection
Herpes Zoster
Molluscum contagiosum
How will HSV infection differ in HIV pts than normal pts?
HIV pts will be at a higher risk for what with HSV?
treat the same for herpes zoster
Occur more frequently and tend to be more severe
Due to risk of dissemination; ALL must be treated with oral medications
Molluscum contagiosum tends to spread how?
How should we treat it?
Tend to spread widely, but not disseminate
Treat with liquid nitrogen
what is the most common bacterial cause of skin infections in HIV+ patients?
What should we always assume about staph infections in HIV pts?
Staph
ALWAYS assume it is methicillin-resistant Staph (MRSA) and treat accordingly
What is a Zoonotic infection from fleas of domesticated cats
Raised, red, highly vascular lesions that can mimic Kaposi’s?
Bacillary angiomatosis
Bartonella henselae and Bartonella quintana
What are common symptoms of Bacillary angiomatosis?
4
Fever is common with bone, lymph node, and liver involvement
Where will kaposi’s sarcoma appear in an HIV pts?
What places should we examine for these?
5
Lesions may appear ANYWHERE
Careful examination of the eyelids, conjunctiva, pinnae, palate, and toe webs
What other kind of malignancy is common in AIDS pts?
Where does it originate from and what kind of tumor is it?
Depending on the advancement of disease and CD-4 count; prognosis with this tumor may be what?
Non-Hodgkin’s Lymphoma
Usually of B-cell origin and are large cell tumors
(most are extranodal)
Only for a few months survival
Whats the most common GYN symtpom of AIDS?
What is present in about 40% of women that requires a pap smear every 6 motnhs?
Recurrent vaginal candidias
Cervical dysplasia
What is much more aggressive in HIV pts and they are more apt to die from cervical cancer than HIV?
What other GYN disease is common in HIV pts?
cervical neoplasia (was so common it was added to the definition of AIDS by CDC)
PID
