HIV emergencies Flashcards
35 yo man, CD4 count 500, right sided chest pleuritic chest pain and temperature of 38.5 degrees.
What is the most likely causative organisms?
Adenovirus
Aspergillus fumigatus
Cryptococcus neoformans
Cytomegalovirus
Haemophilus influenzae
Histoplasma capsulatum
Mycobacterium avium cellulare
Mycobacterium TB
Pneumocystis jiroveci
Pseudomonas aeruginosa
Staphylococcus aureus
Streptococcus pneumonia
Streptococcus pneumoniae
- This is because his CD4 is normal, so we immediately can cross out every cause of disease in low CD4
35 yo man, CD4 of 100, SOB on exertion and a temperature of 38
Adenovirus
Aspergillus fumigatus
Cryptococcus neoformans
Cytomegalovirus
Haemophilus influenzae
Histoplasma capsulatum
Mycobacterium avium cellulare
Mycobacterium TB
Pneumocystis jiroveci
Pseudomonas aeruginosa
Staphylococcus aureus
Streptococcus pneumonia
200 – cut-off for CD4 count when we start worrying about opportunistic infections
Answer: pneumocystis jiroveci – most common opportunistic respiratory infection in ppl with low CD4 count
35 yo lady from Zimbabwe, CD4 of 300, temperature of 37.8
Adenovirus
Aspergillus fumigatus
Cryptococcus neoformans
Cytomegalovirus
Haemophilus influenzae
Histoplasma capsulatum
Mycobacterium avium cellulare
Mycobacterium TB
Pneumocystis jiroveci
Pseudomonas aeruginosa
Staphylococcus aureus
Streptococcus pneumonia
Zimbabwe – high prevalence of TB & HIV (they overlap & are synergistic)
35 yo pigeon fancier, CD4 of 50, temperature 38
Adenovirus
Aspergillus fumigatus
Cryptococcus neoformans
Cytomegalovirus
Haemophilus influenzae
Histoplasma capsulatum
Mycobacterium avium cellulare
Mycobacterium TB
Pneumocystis jiroveci
Pseudomonas aeruginosa
Staphylococcus aureus
Streptococcus pneumonia
Cryptococcus neoformans
- Opportunistic fungal infection carried by birds
Forms space occupying lesions (clumps of fungus) in the lungs, brain, skin, eyes
NB - Mycobacterium avium intracellulare has nothing to do with birds, it is a water-born infection; put in exam question as a trap
35 yo injecting drug user, CD4 of 300, temperature 38
Adenovirus
Aspergillus fumigatus
Cryptococcus neoformans
Cytomegalovirus
Haemophilus influenzae
Histoplasma capsulatum
Mycobacterium avium cellulare
Mycobacterium TB
Pneumocystis jiroveci
Pseudomonas aeruginosa
Staphylococcus aureus
Streptococcus pneumonia
Staphylococcus aureus
Staph lives on skin normally, can cause problems if wound present, IV lines, IV injections
Characteristic thing on CXR à cavitating consolidations (air spaces)
40 yo man, returned from Thailand 2 months earlies, presents with generalised rash, systemic malaise, generalised lymphadenopathy and low-grade fever. Admits to unprotected sex with a girl he met in a bar in Bangkok.
Burkitts lymphoma
Chancroid
Epstein Barr virus
Genital herpes
Hodgkin’s lymphoma
Kaposi’s sarcoma
Lymphogranuloma venereum
Non Hodgkin’s lymphoma
Persistent generalised lymphadenopathy
Rubella
Sarcoidosis
Syphilis
Syphilis
Secondary syphilis rash –> Maculopapular rash, widely disseminated, non-itchy, red, involves palms and soles (which other rashes don’t) à not everybody gets it, depends on the immune response
Timecourse –> 4-6 weeks for secondary syphilis since exposure
25 yo man, recently diagnosed with HIV, prominent, non-tender glands in neck and axillae. Otherwise well with CD4 of 550 and viral load of 25000 copies per ml.
Burkitts lymphoma
Chancroid
Epstein Barr virus
Genital herpes
Hodgkin’s lymphoma
Kaposi’s sarcoma
Lymphogranuloma venereum
Non Hodgkin’s lymphoma
Persistent generalised lymphadenopathy
Rubella
Sarcoidosis
Syphilis
Persistent generalised lymphadenopathy (PGL)
Does not do anything, entirely benign
Can occur anywhere where lymph nodes are
Important to document that it is there
Sometimes goes away, sometimes does not
30 yo man, HIV+, malaise, weakness, anaemia. Low-grade fever and increasingly unwell over several weeks. CD4 of 100. CT scan reveals enlarged hilar and para-aortic lymph nodes.
Burkitts lymphoma
Chancroid
Epstein Barr virus
Genital herpes
Hodgkin’s lymphoma
Kaposi’s sarcoma
Lymphogranuloma venereum
Non Hodgkin’s lymphoma
Persistent generalised lymphadenopathy
Rubella
Sarcoidosis
Syphilis
30 yo man, HIV+, malaise, weakness, anaemia. Low-grade fever and increasingly unwell over several weeks. CD4 of 100. CT scan reveals enlarged hilar and para-aortic lymph nodes.
Non Hodgkin’s lymphoma
- most common lymphoma in HIV
40 yo man, multiple purple-brown lesions on the trunk and face. Oral lesions. HIV positive, CD4 of 53.
Cause?
Kaposi’s sarcoma
Can get it anywhere –>** tip of the nose is quite common, gut, viscera (e.g. lung), skin**
AIDS defining diagnosis
Caused by Human Herpes Virus 8 (HHV8) so Kaposi’s is a virally derived cancer
It is a cancer, but behaves like opportunistic infection
What is the next appropriate management step?
Why? [1]
Advanced HIV, headache, fever, recent grand mal seizure. CT head unremarkable.
Lumbar puncture
- Looking for cryptococcal meningitis.
Need to check CT head before lumbar puncture, because doing an LP on someone with raised ICP will kill the pt
What is the next appropriate management step?
Why? [1]
Pt with CD4 of 50, SOB, non-productive cough and fever. CXR normal.
Bronchoscopy and alveolar lavage
- Looking for PCP
- So majority of people will have abnormal CXR with this actually but this is not impossible; mean exam question
What is the next appropriate management step?
Why? [1]
IVDU, with HIV and hep C, AST twice the normal range.
Liver biopsy
What is the next appropriate management step?
Why? [1]
HIV+ pt, CD4 of 75, 2 right hemispheric lesions unchanged after 2 weeks tx with sulphadiazine and pyrimethamine (tx for toxoplasmosis)
Brain biopsy
- We don’t do biopsies lightly
Point is here, that you’ve made a diagnosis and it is not responding to treatment, so we need to find out what is going on
- This is likely to by a lymphoma
Brain lumps in HIV patients:
- Toxoplasmosis (multiple ring-enhancing lesions with swelling around them)
- lymphoma (single non-enhancing lesion)
Toxoplasmosis and lymphoma do not always fit text-book descriptions, they can look alike to each other at times
What is the next appropriate management step?
Why? [1]
HIV+ pt, CD4 of 25, severe retrosternal odynophagia, low grade fever, no oral candida.
Upper gastro-intestinal endoscopy
Looking for:
- Cytomegalovirus, Oesophageal candidiasis (but if not in the mouth, then unlikely to be further down the GI tract), Kaposi’s sarcoma (but does not usually cause pain)
Select the most likely diagnosis for pt with confusion.
47 yo man acting inappropriately for several months; uncharacteristically aggressive and moody. Stopped all antiretroviral dxs 6 months earlier, complaining of intolerable side effects. O/E apyrexial, no focal neurology. 7/10 MMSE with mistakes on memory questions. CD4 of 56, bloods normal. CT brain shows generalised cerebral atrophy and widened sulci. CSF pressure, cell count, protein, glucose, Z-N stain and India ink stain are all normal
Alcohol intoxication
CMV encephalitis
CNS lymphoma
Cryptococcal meningitis
HIV associated dementia
Progressive multifocal leukoencephalopathy
Toxoplasmosis
Tuberculosis meningitis
HIV associated dementia
Tx à restart antiretroviral therapy to get rid of viral replication in the brain; some ppl improve a bit, some will stabilise, for some it may have gone too far for any change; no specific dementia tx
