HIV Disease: Opportunistic Infx's and Co-Morbidities Flashcards
1
Q
Complications of HIV
2:
A
- Opportunistic Infxs
- Co-morbs
2
Q
Comps of HIV Disease
Opportunistic Infxs vs Co-morbidities
Whats the main difference?
A
You will see Opportunistic Infxs in pts w/ HIV who are NOT successfully tx’d w/ ART
3
Q
Comps of HIV Disease
Opportunistic Infxs
A
Seen in people w/ suppressed immune systems such as pts w/ HIV who are NOT successfully treated w/ ART
4
Q
Comps of HIV Disease
Co-morbs
A
Seen in SOME HIV+ people→ EVEN those who ARE successfully treated w/ ART***
5
Q
Opportunistic Infxs come from
Well…one contributor..
A
LOW CD4 counts
6
Q
HOW can a person who is HIV+ avoid getting an opportunistic infx?
A
- Take ART EVERY DAY (prn/prescribed)
-
Goal:
- NON-detectable lvls
- Maint CD4 count so immune system can function
7
Q
Opportunistic Infections
Kaposi’s Sarcoma
A
- Skin, mucous membranes
-
MAY affect lymphatic system
- Lymphedema
- Painful LEs
8
Q
Opportunistic Infections
Pneumocystis carinii pneumonia (PCP)
A
Think “Fungal” one*
Also….”Pneumo”→ LUNGS!
- Up to 85% of healthy adults possess antibodies
- Fever, dyspnea, hypoxia
9
Q
These are ESP. in Compromised immune systems
2:
A
TB
Non-Hodgkin’s Lymphoma
10
Q
Opportunistic Infections
Oral thrush (Candidiasis)
A
*Fungal also!!
11
Q
Opportunistic Infections
Mycobacterium** Avium (MAC)**
A
INITIALLY affect GI and Pulmonary tracts
12
Q
Opportunistic Infections
Tuberculosis (TB)
A
- RE-surgence in NON-HIV pops in poor urban areas**
- Up to ⅓ HIV+ individuals coinfected w/ Myobacterium TB
- 23% deaths due to TB***
13
Q
Opportunistic Infections
Non-Hodgkin’s Lymphoma
A
Know it exists as an opportunistic infx
along w/ TB→ ESPECIALLY in compromised immune systems
14
Q
This tumor is RARE in NON-HIV population
A
Cerebral Lymphoma
15
Q
Neuro comps of HIV:
Caused by 4:
A
-
Specific tumors:
-
Cerebral lymphoma
- NOTE: this is RARE in NON-HIV pop.
-
Cerebral lymphoma
- Opportunistic infxs
- PRIMARY HIV infx
- Autoimmune rxns*
16
Q
Neuro comps of HIV
Can include:
A
- Peripheral neuropathies* (COMMON)
- Cog impairs
- SZs
- Dementia
- Para/Hemiplegia
- Other focal deficits→ depending upon location of patho.
17
Q
Opportunistic CNS Infxs
Explain how we get them there…
A
- Blood/brain barrier (BBB) usually prevents entry of infectious material
-
HIV is able to cross BBB**
- maybe on its own, maybe in infected macrophages and T-cells
- Even in a normal immune system→ LESS immune protection in CNS vs rest of body:
- NO lymphatic system
- LOWER antibody lvls
- FEWER WBCs
18
Q
Even in a normal immune system→ LESS immune protection in CNS vs rest of body:
3 reasons WHY?
A
- NO lymphatic system
- LOWER antibody lvls
- FEWER WBCs
19
Q
CNS Opportunistic Infx
Meningitis
In general…
A
- Inflammation of meninges of the brain and/or SC
- *USUALLY a complication of another infx
-
Sx’s:
- HA, nausea, painful stiff neck, altered LOC
- Usually extends into cortex and SC
- Potentially severe comps
20
Q
CNS Opportunistic Infx
Meningitis
Cryptococcal Meningitis
A
-
MOST COMMON FUNGAL INFX IN THE CNS***
- ~5% of people w/ AIDS
- Infx usually limited to meninges→ Sxs similar to meningitis
21
Q
MOST COMMON FUNGAL INFX IN THE CNS
~5% of people w/ AIDS
A
Cryptococcal Meningitis
22
Q
This CNS Opportunistic Infx often Co-Exists w/ Meningitis
A
Encephalitis
23
Q
CNS Opportunistic Infx
Encephalitis
A
- Gen inflammation of Parenchyma
- Cause MAY be Viral
- Herpes simplex, Herpes Zoster, Cytomegalovirus (CMV)
- Cause MAY be Viral
-
Findings:
- Aphasia, SZs, hemiparesis, s/s intracranial mass, fever, HA
- *Similar to, but distinct from, Meningitis
- **OFTEN COEXIST!
24
Q
CNS Opportunistic Infx
Brain Abscess
A
- Due to local infx, OR spread from distant infx
- INC incidence w/ exotic protozoan OR fungal organisms
- Abscessed area becomes→ Necrotic and encapsulated
-
Sx risk:
- Exposes CNS structures to other antigens
25
Medical Tx for Brain Abscess
* **Antibiotics→** MUST cross BBB to be **effective**
* Intrathecal tx often used BUT:
* **Neurotoxic SEs**
* **Drug conc LOW in Lat. ventricles**
* **Incision and drainage**
26
CNS Opportunistic Infx
## Footnote
**Cerebral Toxoplasmosis**
**ALL STUFF**
* **Cause→** reactivation of _dormant_ toxoplasma cysts (T. gondii protozoan)
* Oocysts excreted by cats; eggs survive in soil (litter) for extd pds of time
* **\*MOST COMMON _INTRACRANIAL_ infx in PWAIDS**
* 80-90% w/ CD4 count \<100\*
* **Deficits→** Focal
* SZ, hemiparesis, ataxia, aphasia, HA, mental status change, confusion, lethargy
27
MOST COMMON **INTRACRANIAL INFX in PWAIDS**
Cerebral Toxoplasmosis
28
Cerebral Toxoplasmosis
## Footnote
**MOST common _intracranial infx_ in PWAIDS**
**Potentially curable?**
_POTENTIALLY curable_ w/ **EARLY Tx**
**\*Relapses common (in compromised immune systems)**
29
Cerebral Toxoplasmosis
## Footnote
**MOST common intracranial infx in PWAIDS**
**PREVENTION for PW HIV:**
* Gloves working in garden
* Avoid raw/undercooked meat
* Wash hands after handling raw meat/veggies
* Avoid changing litter box (if cats) or use gloves/mask
30
This **DEmyelinating disease (Opportunistic Infx) is RARE**
Progressive Multifocal Leukoencephalopathy (PML)
31
CNS Opportunistic Infx
## Footnote
**Progressive Multifocal Leukoencephalopathy (PML)**
* **Demyelinating dis.**
* Cause→ **papoVIRUS→** Present, BUT _dormant in brain most people_
* **RARE!→** \<1% OF PWAIDS
* **SEVERE neuro sx's may lead to death**
32
Cytomegalovirus (CMV)
Think…. “OPTIC”!!!
* **Primarily _Optic_ structures**
* **CAN affect GI and respiratory systems**
33
Comorbs/Complications can be seen in _________ treated w/ \_\_\_\_\_\_\_\_
Long term survivors; treated w/ **ART**
34
MSK **Complications** are mostly found _________ in disease process
LATE
35
MSK **Complications** a frequently a ________ of ________ resulting in \_\_\_\_\_\_\_\_\_\_\_\_\_
**2\* complication** of **neurologic deficits** resulting in **improper mechanics of mvmt and compensatory strategeis**
36
MSK Complications
## Footnote
**How and leads to what?**
**2\* complication** of **neuro deficits** resulting in **improper mechanics of mvmt and compensatory strategies**
37
When are **MSK complications found ?**
LATE in disease process
38
SC patho **specific to people w/ AIDS**
Vacuolar Myelopathy
39
**COMORBIDITIES**
Vacuolar Myelopathy
* SC patho **specific to PWAIDS**
* **Due to→** macrophages in lateral and post. columns of SC
* **Sx's:**
* weakness, spasticity, ataxia, sensory changes, reflex changes (Hoffman's)
* **Later→** urinary/fecal incont, dementia
* \*Variable progression over time
40
**COMORBIDITIES**
**MOST COMMON _NEUROLOGICAL COMPLICATION OF AIDS_\*\*\***
AIDS DEMENTIA COMPLEX
41
**COMORBIDITIES**
AIDS DEMENTIA COMPLEX
MOST COMMON _NEUROLOGIC COMPLICATION_ OF AIDS\*\*\*
42
**COMORBIDITIES**
Neuro complication→ **AIDS Dementia Complex**
\*MOST COMMON NEURO COMPLICATION OF AIDS
* Thought to be due to **HIV infx in brain**
* **Progressive** cog loss w/ motor and behavioral dysf.
* **Early signs:**
* Apathy, social w/draw, depression, Diff concentration and complex mental tasks
43
MOST COMMON _COMPLICATION_ of HIV Disease (NOTE just “complication”)
Peripheral Neuropathy
44
**COMORBIDITIES**
Peripheral Neuropathy
Most common _complication_ of **HIV Disease**
45
**COMORBIDITIES**
Peripheral Neuropathy
\*most common comp. of HIV dis.
**3 types:**
1. Distal Sensory Polyneuropathy (DSP)→ **MOST COMMON\***
1. **Stocking-glove** numbness, parasthesia, burning
2. Demyelinating Polyneuropathy
3. Mononeuropathy
46
What should you remember about **Peripheral Neuropathy?**
**_DISTAL_** MUSCLES!!!!
47
Peripheral Neuropathy: **Issues for PT**
* **_DISTAL WEAKNESS_** in **advanced cases;** weakness in foot mm's (intrinsic and extrinsic)
* PROnation, Tendinitis
* Grip weakness, balance/sensory/proprio deficits
* Gait disturbs, mvmt disorders
* **PAIN!!!!**
48
Kietrys Study Example DSP
see pics
49
Another Kietrys Study Example DSP
see pics
50
What is **Myopathy ?**
**Inflammatory** disease of **mm tissue**
51
**COMORBIDITIES**
HIV Associated Myopathy
**_Primarily_ WHERE?**
**_PROXIMAL_ MUSCLES!!!**
Trunk, shoulder girdles, pelvic girdles
52
DSP vs HIV ASSOCIATED MYOPATHY
DSP→ **Distal mm's** (just remember **D**SP, **D**istal..both start w/ **D!!)**
HIV Associated Myopathy→ **Proximal mm's**
53
**COMORBIDITIES**
HIV Associated Myopathy
**What _etiology_ suspected?**
**Autoimmune** etiology
54
HIV Associated Myopathy
\***Proximal mm's!**
* **Progressive,** symmetric, PAINLESS, weakness of **Proximal limb mm's+trunk**
* Biopsy→ **muscle fiber necrosis**
* **Autoimmune etiology suspected\***
55
W/ Myopathy…
## Footnote
**Appropriate interventions?**
GENTLE ROM & stretching **as tolerated** ONLY!
56
**COMORBIDITIES**
**Myopathy**
* **Inflammatory** dis. of **muscle**
* **Etiology→** MAY be related to **zidovudine (AZT)** and **chronic dis. process**
* **Sx's→** PROXIMAL weakness, diffuse aching, “myalgia”
* **Dx→** serial **CPK lvls (**leaks as mm destroyed), EMG, mm biopsy
57
**COMORBIDITIES**
**_Acute_, inflammatory Myopathy**
* ELEVATING serial CPK lvls
58
**COMORBIDITIES**
**Chronic** **Myopathy**
CPK lvls DECLINING toward NORMAL
\*NOTE: **when steroids kick in**
59
Acute, inflamm myopathy vs Chronic myopathy
**ACUTE→** ELEVATING CPK lvls
**CHRONIC→** CPK lvls DECLINE TOWARDS NORMAL
60
**Acute, inflammatory Myopathy**
**PT + Medical Mx:**
* **PT→**
* AVOID strenuous activity, **OK to do _gentle_ ROM and stretching as tolerated**
* **Med Mx→**
* anti-inflamms and analgesics
* \*nutritional support
61
Chronic Myopathy
## Footnote
**PT:**
* **PT→**
* SLOWLY progress to **PREs** w/ **emphasis on _proximal musculature_\*\*\***
62
**COMORBIDITIES**
This is the one w/ the **Truncal obesity\*\*\*\*\*\*\*\***
Lipodystrophy
63
**COMORBIDITIES**
**Lipodystrophy**
The “truncal obesity” one\*\*\*
* **Truncal obesity→** INCd subQ and visceral fat
* enlarged **dorsocervical fat pad (**whale hump)
* atrophy and fat wasting in **extremities** and **face** (remember the calves, sunken face!!!)
* \*Insulin resistance
64
**COMORBIDITIES**
**Lipodystrophy Diagnosis:**
**Observation,** bioimpedance abnorms, abnorm blood **lipids** (HypER**lipidemia,** HypER**glycemia),** body comp changes, metabolic changes
65
**COMORBIDITIES**
**Lipodystrophy Etiology:**
UNCLEAR: **related to _prolonged use of antiviral meds_ (**PIs, NNRTIs), OR chronic dis. process
66
**COMORBIDITIES**
**Lipodystrophy Interventions:**
Aerobic exercise and PREs, growth hormones, testosterone, anabolic steroids, nutrition support
67
Dealing w/ Body Composition Changes
## Footnote
**(HIV Related Muscle Wasting)**
**Egrifta**
Egrifta= **precursor to HGH**
## Footnote
**See study pics/results**
68
Long term survivors of HIV aka **People Living w/ HIV (PLHIV)**
## Footnote
**this is common**
Chronic pain
69
**Chronic Pain in PLHIV**
* **Prev→** 39-55%
* **HIGHER + higher severity of pain in _indigent population_**
* **Concurrent psychiatric illness→** 40% more likely pain
* **Concurrent subs abuse→** higher pain severity and disruption daily function
70
**Multifactorial Etiology of _Chronic Pain_ in PLHIV:**
* **Direct effects** of HIV infx
* **Chronic inflamm** and immune activation
* **SEs** of ART drugs/other drugs
* **Neuro mechs**
* Comorbs/Multimorbs
* **Opportunistic infx's\*\*\***
* Aging/frailty
* Psychosocial influences
* **Rx opiods misuse/heroin use**
* Gender/ethnic diffs→ perception/expression of pain
71
**2 MOST COMMON CHRONIC PAIN AREAS**
+ A 3rd and example
1. \***SPINAL**
2. **\*ARTHRALGIA** (Jt pain)
3. Neuropathic (Peripheral neuropathy)
