HIV Opportunistic Infections Flashcards
Kaposi is what type of HHV?
HHV-8
If CD4=10, with pigmented firm macular lesions all over with fevers, what is the most common lesions?
Kaposi, bartonella
what are the cardinal AIDS-defining illness?
PCTDCK (pneumocystis pneumonia, CMV retinitis, toxoplasma encephalitis, Disseminated MAC, cryptosporidiosis, Kaposi sarcoma)
what is the best indicator for susceptibility for HIV OI?
current CD4 count. Viral load is independent risk factor
which infections are most likely to occur under CD4<100?
MAC, CMV, Histo, Toxo
when to start ART following OI for TB?
If CD4<50 - within 2 weeks of diagnosis. If CD4>50, within 8-12 weeks of diagnosis
when to start ART following OI for cryptococcal meningitis?
If mild and CD4<50, within 2 weeks. For more severe, delay 2-10 weeks
when to start ART following for untreatable OIs like PML, cryptosporidiosis,
start immediately
which HIV patients need primary prophylaxis?
PCP (CD4<200), Toxo (CD4<100, positive anti Toxo IgG), MAC (CD4<50 - technically depending upon guideline)
which diseases do you need chronic suppression?
PCP, Toxo, MAC, CMV, Cryptococus, histo, coccidio
which OIs would you consider secondary prophylaxis?
Candida, HSV, VZV if recurrences were frequent/severe
Which OIs is primary prophylaxis not routinely recommended?
candida, Cryptococcus, HSV, VZV, CMV, Mac
When would you discontinue primary prophylaxis?
PCP/Toxo >200 x 3 months on appropriate ART
when do you primary prophylaxis for coccidiomycosis?
within the endemic area, yearly testing for seronegative patients. If positive IgM or IgG, prophylaxis if CD4<250
when/what do you give chronic maintenance therapy for cocciomycosis?
Triazole for life if coccidiomycosis meningitis. If non-meningeal disease, prophylaxis for detectable VL or CD4<250
When would you not give live vaccines?
under CD4<200 MMR, Varicella, HSV
what are the common HIV pulmonary diseases?
PHAT; Pneumococcus, pneumocystis, Hemophilus, atypicals/virals, and TB
what are the uncommon HIV associated pulmonary disorders?
T-CHALKS; Toxoplasma, cocci, histo, aspergillus, lymphoma, kaposi sarcoma, Staphylococci
what are the rare HIV associated pulmonary disorders/
CMV, MAC, HSV (almost always the wrong answer on the exam, usually a colonizer)
what are HIV-related drug respiratory effects you need to watch out for?
abacavir, dapsone
what history findings suggest PCP, TB, viral pneumonia in HIV patient
> 3day onset of symptoms with scant sputum.
How is PCP transmitted?
respiratory
what is the host susceptibility in HIV patients to PCP risk factors?
CD4<200, CD4%<14
what are the non-HIV underlying diseases that predict PCP?
ALL, HTLV1, transplants; steroids>4 weeks, Anti-TNF (campath) antibody, rituximab, immunosuppression
what is the most frequent radiological pattern associated with PCP?
diffuse symmetrical interstitial infiltrates progressing to diffuse alveolar process, eventually causing upper lobe cysts, pneumothorax (cyst and BPF), consolidation
how would you diagnose pneumocystitis?
BAL and DFA. No useful serum antibody or PCR test.
what would rule out PCP?
negative BAL and negative DFA. Generally, a normal CT scan.
what would suggest PCP?
positive DFA. Positive BAL PCR might be PCP. Beta Glucan and LDH might be sensitive.
what are the specific therapies for PCP?
bactrim, Parenteral pentamidine (toxicities), Atovaquone (takes 4 days), and clindamycin-primaquine (if not worried about C.Diff) +/- adjunctive corticosteroids (moderate, PO2<70)).
what is the presumptive logic on giving steroids with PCP treatment?
Kill organism, release toxins, antigen causes more inflammatory response. Prevent drug related exacerbation/intubation.
disassociation with PO2 sat and oxygen saturation, suspect what in a HIV patient? tx?
methemoglobinemia with dapsone/primaquine. Tx with methylene blue or exchange transfusions
what dangerous side effects associated with IV pentamidine?
TDP, hypoglycemia, hypotension-rate related, AKI, leukoepnia
the patient needs PCP treatment with PO2=84, but has a severe exfoliative rash with Bactrim. What can you use to treat?
IV pentamidine
what anti-infectives can cause prolong QT?
Chloroquine, pentamidine, fungals, quinolones, and clarithromycin
what are the side effects associated with Bactrim and Pyrimethamine-Sulfadizine?
Leukoepnia, thrombotyoepnia, transaminitis, AKI, hyperkalemia.
what are the side effects associated with atovaquone?
absorption if low-fat diet, rash, GI, LFTs
what is the 1-3rd choices for PCP pneumonia prophylaxis?
(1) Bactrim (2) dapsone (3) aerosol pentamidine, intermittent dapsone-pyrimethamine, atovaquone, monthly IV pentamidine
when do you start PCP prophylaxis?
Start CD4<200 (14%)
when do you stop and restart PCP prophylaxis?
stop when CD4>200 x 3 months. Consider if CD4 1002-00 and VL<50 x 3 months). Restart if CD4<200
How would you manage a patient that needs PCP prophylaxis w/history of Bactrim allergy?
oral dose escalation, lower daily/weekly dose, atovaquone, aerosol pentamidine, dapsone (50% cross-reactivity)
what are the two most common causes of space-occupying lesions in the US?
Lymphoma and toxoplasmosis
space-occupying lesion from brazil?
trypanosomiasis
transmission of toxoplasma?
feline feces, rare meat (lamb>beef>Pork), congenital
ddx of CNS mass lesions in HIV/AIDs?
Bacterial, lymphoma, toxoplasmosis, tuberculosis, nocardia, fungus, chagoma, kaposi, glioblastoma (BLT TNF CKG)
what labs do you obtain in patient with CNS mass lesions/
Serology - Toxo igG, PCR, CrAg; blood cultures including afb, fungus; CSF CrAg, CSF PCR EBV, CMV, toxo, urine and serum histo antigen
Empiric dx of CNS toxo?
Need all of the radiological findings, CD4<100, Toxo IgG antibody, response to therapy within 2 weeks.
The preferred regimen of cerebral toxo?
sulfadiazine plus pyrimethamine plus leucovorin
alternate regimens for cerebral toxo treatment?
bactrim OR clindamycin plus pyrimethamine or Atovaquone +/- pyrimethamine
what are adjunctive therapies for CNS toxoplasmosis?
corticosteroids only if increased ICP/sympotms; anticonvulsants only after first seizure
Indications for primary prevention of HIV toxoplasmosis?
positive toxoplasmosis IgG + CD4<100
the preferred treatment of primary prevention of toxoplasmosis?
Bactrim Ds q daily
alternative treatments for primary prevention of toxoplasmosis?
dapsone-pyrimethamine; Atovaquone + pyrimethamine
what would you give for primary prevention of toxoplasmosis if they are already on aerosol pentamidine or dapsone for PCP prophylaxis?
if on dapsone, add pyrimethamine. If on aerosol pentamidine, rethink toxo options
what are the mycobacterial infections associated with HIV infected patients?
BATH -GMCSX (Bovis/BCG, avium complex, tuberculosis hemophilum, genovense, malmoense, chleonei, scrofulaceum, xenopi
which mycobacterial infections have disseminated presentations?
BATGS - BCG, bovis, avium complex, TB, genovense, scrofulaceum
SSTI mycobacterial presentations in HIV?
chelonei (bone too), hemophilum (cutaneous abscess),
which mycobacterial have lung presentations in HIV?
malmoense (cavitary lung/CNS ring lesions), Xenopi (lung nodules/infiltrates)
what CD4/VL counts have risk factors of MAI?
CD4<50 or high VL
when do you stop MAC chronic suppression?
CD4>100 x 6 months and therapy >12 months
epidemiological picutre of CD4 count in patients with cryptococcal meningitis?
CD4<50
Induction therapy for cryptococcal meningitis?
Ambisome 3-4mg/kg qd + Flucytosine 25mg/kg QID x 2 weeks. QD LP if CSF pressure>20
Consolidtion therapy for cryptococcal meningitis?
Fluconazole 400mg PO qd x 8 weeks
Maintenance therapy for cryptococcal meningitis?
Fluconazole 00mg PO qd >52 weeks
Role for dexamethasone for cryptococcal meningitis?
None; maybe if increased ICP/ARDs
How often would you do LPs for cryptococcal meningitis?
continue daily until stable for at least 2 days; shunt if daily LPs prolonged
When do you stop therapy for cryptococcal meningitis?
CD4>100 x 3months with VL<50 due to ART + 12 months of cryptococcal therapy. LP optional to confirm CSf culture negative.
what are the main CMV syndromes in HIV patients?
ventriculitis. colitis, Retinitis,
CMV syndromes in HIV patients including rare?
VCR PEAR; Ventriculitis, Colitis, Retinitis, pneumonia, esophagitis, adrenalitis, radiculopathy
How does CMV differ in HIV patients?
crosses BBB with high frequency, rarely occurs with CD4 counts >50
what is the treatment for CMV retinitis?
INtravitreal ganciclovir x 4-7 doses over 1-2 weeks; IV ganciclovir or valganciclovir 900mg PO BID x 14-21 days then qD
what is the treatment for CMV colitis?
Ganciclovir, valganciclovir, foscarnet
what are the reasons for late failure for CMV therapy treatment?
UL97 (phosphotransferase gene) with low levels no cross resistance to foscarnet/cidofovir, many respond to high dose GCV. UL54 (polymerase gene)
how can you tell the difference between CMV retinitis vs IRIS/IRU ?
uveitis has inflammation in vitreous/aqueous. Uveitis would respond to steroids
what HIV diseases are associated with EBV?
oral hairy leukoplakia, CNS lymphoma, and effusion cell lymphoma
how is the best way to think of toxoplasmosis?
mononucleosis without sore throat (fever/lymphadenopathy)
common presentation of normal immunity with toxoplasmosis?
retinochorioiditis
classic radiographic finding of CNS toxoplasmosis
single unenhanced lesion in the basal ganglia
treatment of cryptosporidium and size/stain?
4 um; acid fast;ART; nitazoxanide or paraomomycin
treatment of cyclospra and size/stain?
10 um;Cipro; acid fast; bactrim
treatment of cystoisospora and size/stain?
20um; acid fast; Cipro, pyrimethamine; bactrim
treatment of microsporidia and size/stain?
1-5 um; ART, albendazole, fumagilin
what does microsporidia cause in immunocompetent patients?
self-limiting diarrhea
what are the toxicities associated with albendazole?
neutropenia, CNS (dizziness), abdominal pain, hepatitis, hair loss
what is the treatment for microsporidiosis?
albendazole
what are the key HIV encephalopathies?
PML, HIVE, CMV
who should receive prophylaxis against MAC?
If ART started immediately, no prophylaxis. But, people with HIV not receiving ART, should get prophylaxis if CD4<50. It should be discontinued if people on ART.
what is the most common syndrome associated with IRIS?
MAC
which NTM can be grown only at 32-degree centigrade with iron-enriched medium?
Mycobacterium haemophilum
