HIV II Flashcards
Examples of things that should be considered in a DDx of an HIV patient (9)
EBV mononucleosis/CMV HSV Influenza Rubella Viral Hepatitis Toxoplasmosis Syphilis/Gon./Chlam. Rickettsia/Lyme Strep
Important things to consider with Drug Resistance Testing
Identification of resistance mutations at entry to care can optimize treatment outcomes.
Interpret in combination with history of ARV exposure and adherence in mind.
Important Vaccinations to check on…
Avoid Live Vaccines (MMR and Zoster) Pneumococcal vaccine, Hep A and B Influenza HPV Hemophilius Influenza Varicella vaccine Tetanus
Symptoms of Pneumocystis jirovecii
Gradual onset fever, dry cough, dyspnea
Imaging for Pneumocystis jirovecii
Chest xray with diffuse bilateral interstitial infiltrates
CT if necessary
How to diagnose Pneumocystis jirovecii
Immunoflourescent antibody staining
Bronchoscopy/BAL (sensitivity 97-100%)
Treatment for Pneumocystis jirovecii
IV Bactrim or Pentamidine, PO Bactrim, TMP-dapsone, clindamycin-primaquine, or atovaquone
Give corticosteroids if PaO2 drops below 70
What do you use to do prophylaxis for Pneumocystis jirovecii
Bactrim DS or SS daily, can reduce to 3/week
Dapsone daily if G6PD is ok
Add pyrimethamine/leucovorin for Toxo prophylaxis
What happens to CD4 after discontinuing prophylaxis
increase in CD4 by more than 200 for more than 3 months
Symptoms of cryptococcal menningitis
Subacute meningitis w/fever
HA + Malaise
What does cryptococcal menningitis CSF look like?
Lymphocytic pleocytosis
Elevated Protein
Low-normal glucose
OP elevated to over 200
How to diagnose Cryptococcal Menningitis
Serum+CSF crypto Ag
Blood Cultures in up to 75% of cases
CSF fungal culture
Treatment for Cryptococcal Menningitis?
Ampthtericin B and Flucytosine
Maintain with Fluconazole for 8 weeks
How to manage increased intracranial pressure in Cryptococcal infection
If over 250 mmH2O, daily LP recommended
Consider shunt if signs of cerebral edema persist
Symptoms of CMV infection?
End-organ manifestations Retinitis Colitis Esophagitis Neurological Disease
How to diagnose latent tuberculosis in HIV?
Test at diagnosis and annually
PPD or IFN-gamma release
Repeat if tested below 200 CD4
How to treat LTB in an HIV patient
INH daily or twice weekly for 9 months
OR
Rifampin or Rifabutin for 4 months (2nd line)
How does TB present differently in advanced HIV patients?
in CXR - Lower lobe, interstitial and miliary infiltrates
Hilar/Mediastinal Adenopathy
More extrapulmonary manifestations
No granulomas
Clinical presentation of M. avium (MAC) in HIV
Fever Weight Loss Sweats Diarrhea Lymphadenopathy Hepatosplenomegaly
Abnormal lab values in MAC?
Anemia
elevated Alkphos
CD4 below 50
Best way to diagnose MAC?
Blood Culture
Who gets prophylaxis for MAC?
When do you stop?
CD4 below 50
When CD4 is above 100 for at least 3 months
What should you use as prophylaxis for MAC?
Azithromycin or Clarithromycin
Most common symptoms of Toxoplasmosis
Headache Fever Behavioral Lethargy Coord/gait Seizure Coma
How to diagnose Toxoplasmosis
Focal lesions on CT/MRI
CSF – high proteins, moderate mononecueated pleocytosis
DNA PCR (high specificity)
Response to treatment
Signs and symptoms of Primary CNS lymphoma
No Fever Confusion, lethargy, memory loss Hemiparesis/aphasia seizures CN palsy Headache CD4 below 100
How to diagnose Primary CNS lymphoma
Neuroimaging – CT/MRI
CSF – mononucleated pleocytosis, elecated proteins
Epstein Barr virus DNA PCR (pick this one)
How to diagnose Progressive Multifocal Leukoencephalopathy/JC Virus
Brain Biopsy
CSF PCR detection of JCV DNA
Treatment for Progressive Multifocal Leukoencephalopathy/JC Virus
None.
