HIV Infection and Secondary Causes of Immunodeficiency

Question 1

How are immune deficiencies classified?

Answer 1

• Primary and Secondary
• Secondary - much more common than primary

Question 2

What are the clinical features of immune deficiencies?

Answer 2

Question 3

What are the common causes of secondaey immune deficiencies?

Answer 3

Question 4

What drugs cause immune deficiency?

Answer 4

DMARD = Disease modified altering rhuematoid drugs

Question 5

What biologic and cellular therapies cause immune deficiency?

Answer 5

Question 6

How do haematological cancers cause immune deficiency? What types in particular?

Answer 6

Question 7

How can we evaluate secondary immune deficiencies?

Answer 7

Question 8

Describe the FISH method.

Answer 8

lymphocyte < 8 –> worrying

Serum complement - good for lupus

Question 9

What are other front line investigations for immune deficiency?

Answer 9

Question 11

What serum immunoglobulins would you check? What should you keep in mind?

Answer 11

Rituximab - first IgM and then IgG

Question 12

How does serum protein electrophoresis work?

Answer 12

Question 13

What are the second line tests to investigate immune deficiencies?

Answer 13

These are dynamic tests.

Flow cytometry too.

Question 14

What are the third line investigations for immune deficiencies?

Answer 14

Question 15

What is the management of secondary immune deficiencies?

Answer 15

Question 16

When would igG replacement therapy be given?

Answer 16

Question 17

Describe the epidemiology of HIV-1

Answer 17

Question 18

How is HIV-1 care in the UK?

Answer 18

90% HIV is treated

75% successful anti-retroviral treatment

Question 19

What type of virus is HIV-1? How does it infect?

Answer 19

Question 20

What are the stages of HIV infection?

Answer 20

• Virus incoroporates in the first 72 hours
• 3-6 months later comes to a setpoint
• The more virus in blood - the higher risk of transmission
• Virus mutates and you have several strains

Question 21

What are the key concepts of HIV-1 replication cycle?

Answer 21

Question 22

What is the natural progression of T cells immunolofy in HIV infection

Answer 22

• CD4 T cells level drops initially
• Then rises again
• Then drops

Question 23

Describe the humoral immunology of HIV infection

Answer 23

• Initial immune response against GP120
• By the time immune response optimal, lots of mutations

Question 24

Describe the 5 characteristic features of immunology of HIV infection

Answer 24

Question 25

What happens during acute HIV infection?

Answer 25

Question 26

How would you diagnose HIV.1?

Answer 26

Question 27

How would you manage HIV-1?

Answer 27

Question 28

What are the baseline investigations in clinic for HIV

Answer 28

Question 29

What are the HIV specific tests

Answer 29

Question 30

Why do we look at viral load?

Answer 30

Question 31

How does CD4 T cell count and risk of infection correlate in HIV infection?

Answer 31

Question 32

How do clinicians use CD4 T cell counts in HIV?

Answer 32

Question 33

What anti-retroviral therapy is available in the UK?

Answer 33

Protease and integrase inhibitors are most common.

Question 34

What are the uses of anti-retroviral therapy?

Answer 34

Question 35

How does ART work?

Answer 35

Does not get rid of virus - stops replication

Question 36

How do we monitor individuals on ART?

Answer 36

Question 37

What are the challenges for preventing HIV-1 infection

Answer 37

Question 38

What are the strategies for curing HIV-1?

Answer 38

Question 39

Question 2. A 57-year-old male is referred to the Chest clinic with recurrent chest infections, requiring antibiotic therapy. Past medical history reveal lichen planus and a history of surgery for an anterior mediastinal mass 4 year previously. Physical examination show nail candidiasis, sternotomy scar and bi-basal crepitations. A HRCT chest scan shows extensive bronchiectasis. Immune investigation are as follows IgG – 3.1g/L (ref interval 6.4-16.0g/L) IgA – 0.4g/L (ref interval 0.8-3.4g/L) IgM – 0.2g/L (ref interval 0.5-2.0g/L) IgE 500IU/ml (reference interval 3-120IU/ml) B cell count 10cell/ul ( ref interval 100-500) What is the most likely diagnosis? A) Partial antibody deficiency syndrome B) Common variable immune deficiency C) High grade B cell Mediastinal Lymphoma D) Thymoma with antibody deficiency/Good’s syndrome E) Hyper IgE syndrome

Answer 39

Thymoma with antibody deficiency

Question 40

A 65 year-old male with a history of steroid dependent asthma, hypertension, Type 2 Diabetes Mellitus and osteoporosis presents with recurrent chest, sinus, and skin infections. Past medical history of chemotherapy for follicular lymphoma and he has recently completed a 2 year maintenance therapy of 3 monthly rituximab. Current oral medication includes Prednisolone 5mg OD, Losartan 50mg OD, metformin500mg BD, alendronic acid 70mg weekly. Serum immunoglobulins are as follows IgG – 3.9g/L (ref interval 6.4-16.0g/L) IgA – 0.9g/L (ref interval 0.8-3.4g/L) IgM – 0.1g/L (ref interval 0.5-2.0g/L) IgE 200IU/ml (reference interval 3-120IU/ml) Which of the following medication are most likely to have cause antibody deficiency A) Metformin B) Losartan C) Prednisolone D) Alendronic Acid E) Rituximab

Answer 40

Rituximab

Question 41

Which of the following condition are more likely to present in patients with a CD4 T cell counts of more than 350cells/ul A) CMV retinitis, Toxoplasma encephalitis, visceral Kaposi sarcoma B) Herpes zoster, Pulmonary Tuberculosis, Pneumococcal pneumonia C) Pneumocystis jirovecci pneumonia, disseminated MAC, ITP D) EBV CNS lymphoma, oral candida, cryptococcal meningitis E) Cutaneous Kaposi sarcoma, disseminated MAC, HSV infection

Answer 41

B

Question 42

Which of the following statements are true about HIV-1 infection A) Reverse transcription is associated with few errors in copying HIV-1 RNA template B) Preferred option to commence ART in the UK is dual combination therapy containing an integrase inhibitor and NRTI C) HLA-B\*5701 blood test is used to prevent hypersensitivity reaction with protease inhibitors D) Residual immune activation is commonly seen in patients on suppressive ART regimens E) HIV-1 serology point care tests have similar diagnostic performance to 4th generation combined p24antigen/antibody tests

Answer 42

Residual immune activation is commonly seen in patients on suppressive ART regimens