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General ID 2019 > HIV Opportunistic Infections > Flashcards

HIV Opportunistic Infections Flashcards

1
Q

Kaposi is what type of HHV?

A

HHV-8

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2
Q

If CD4=10, with pigmented firm macular lesions all over with fevers, what is the most common lesions?

A

Kaposi, bartonella

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3
Q

what are the cardinal AIDS-defining illness?

A

PCTDCK (pneumocystis pneumonia, CMV retinitis, toxoplasma encephalitis, Disseminated MAC, cryptosporidiosis, Kaposi sarcoma)

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4
Q

what is the best indicator for susceptibility for HIV OI?

A

current CD4 count. Viral load is independent risk factor

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5
Q

which infections are most likely to occur under CD4<100?

A

MAC, CMV, Histo, Toxo

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6
Q

when to start ART following OI for TB?

A

If CD4<50 - within 2 weeks of diagnosis. If CD4>50, within 8-12 weeks of diagnosis

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7
Q

when to start ART following OI for cryptococcal meningitis?

A

If mild and CD4<50, within 2 weeks. For more severe, delay 2-10 weeks

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8
Q

when to start ART following for untreatable OIs like PML, cryptosporidiosis,

A

start immediately

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9
Q

which HIV patients need primary prophylaxis?

A

PCP (CD4<200), Toxo (CD4<100, positive anti Toxo IgG), MAC (CD4<50 - technically depending upon guideline)

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10
Q

which diseases do you need chronic suppression?

A

PCP, Toxo, MAC, CMV, Cryptococus, histo, coccidio

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11
Q

which OIs would you consider secondary prophylaxis?

A

Candida, HSV, VZV if recurrences were frequent/severe

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12
Q

Which OIs is primary prophylaxis not routinely recommended?

A

candida, Cryptococcus, HSV, VZV, CMV, Mac

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13
Q

When would you discontinue primary prophylaxis?

A

PCP/Toxo >200 x 3 months on appropriate ART

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14
Q

when do you primary prophylaxis for coccidiomycosis?

A

within the endemic area, yearly testing for seronegative patients. If positive IgM or IgG, prophylaxis if CD4<250

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15
Q

when/what do you give chronic maintenance therapy for cocciomycosis?

A

Triazole for life if coccidiomycosis meningitis. If non-meningeal disease, prophylaxis for detectable VL or CD4<250

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16
Q

When would you not give live vaccines?

A

under CD4<200 MMR, Varicella, HSV

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17
Q

what are the common HIV pulmonary diseases?

A

PHAT; Pneumococcus, pneumocystis, Hemophilus, atypicals/virals, and TB

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18
Q

what are the uncommon HIV associated pulmonary disorders?

A

T-CHALKS; Toxoplasma, cocci, histo, aspergillus, lymphoma, kaposi sarcoma, Staphylococci

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19
Q

what are the rare HIV associated pulmonary disorders/

A

CMV, MAC, HSV (almost always the wrong answer on the exam, usually a colonizer)

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20
Q

what are HIV-related drug respiratory effects you need to watch out for?

A

abacavir, dapsone

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21
Q

what history findings suggest PCP, TB, viral pneumonia in HIV patient

A

> 3day onset of symptoms with scant sputum.

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22
Q

How is PCP transmitted?

A

respiratory

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23
Q

what is the host susceptibility in HIV patients to PCP risk factors?

A

CD4<200, CD4%<14

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24
Q

what are the non-HIV underlying diseases that predict PCP?

A

ALL, HTLV1, transplants; steroids>4 weeks, Anti-TNF (campath) antibody, rituximab, immunosuppression

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25
Q

what is the most frequent radiological pattern associated with PCP?

A

diffuse symmetrical interstitial infiltrates progressing to diffuse alveolar process, eventually causing upper lobe cysts, pneumothorax (cyst and BPF), consolidation

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26
Q

how would you diagnose pneumocystitis?

A

BAL and DFA. No useful serum antibody or PCR test.

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27
Q

what would rule out PCP?

A

negative BAL and negative DFA. Generally, a normal CT scan.

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28
Q

what would suggest PCP?

A

positive DFA. Positive BAL PCR might be PCP. Beta Glucan and LDH might be sensitive.

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29
Q

what are the specific therapies for PCP?

A

bactrim, Parenteral pentamidine (toxicities), Atovaquone (takes 4 days), and clindamycin-primaquine (if not worried about C.Diff) +/- adjunctive corticosteroids (moderate, PO2<70)).

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30
Q

what is the presumptive logic on giving steroids with PCP treatment?

A

Kill organism, release toxins, antigen causes more inflammatory response. Prevent drug related exacerbation/intubation.

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31
Q

disassociation with PO2 sat and oxygen saturation, suspect what in a HIV patient? tx?

A

methemoglobinemia with dapsone/primaquine. Tx with methylene blue or exchange transfusions

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32
Q

what dangerous side effects associated with IV pentamidine?

A

TDP, hypoglycemia, hypotension-rate related, AKI, leukoepnia

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33
Q

the patient needs PCP treatment with PO2=84, but has a severe exfoliative rash with Bactrim. What can you use to treat?

A

IV pentamidine

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34
Q

what anti-infectives can cause prolong QT?

A

Chloroquine, pentamidine, fungals, quinolones, and clarithromycin

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35
Q

what are the side effects associated with Bactrim and Pyrimethamine-Sulfadizine?

A

Leukoepnia, thrombotyoepnia, transaminitis, AKI, hyperkalemia.

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36
Q

what are the side effects associated with atovaquone?

A

absorption if low-fat diet, rash, GI, LFTs

37
Q

what is the 1-3rd choices for PCP pneumonia prophylaxis?

A

(1) Bactrim (2) dapsone (3) aerosol pentamidine, intermittent dapsone-pyrimethamine, atovaquone, monthly IV pentamidine

38
Q

when do you start PCP prophylaxis?

A

Start CD4<200 (14%)

39
Q

when do you stop and restart PCP prophylaxis?

A

stop when CD4>200 x 3 months. Consider if CD4 1002-00 and VL<50 x 3 months). Restart if CD4<200

40
Q

How would you manage a patient that needs PCP prophylaxis w/history of Bactrim allergy?

A

oral dose escalation, lower daily/weekly dose, atovaquone, aerosol pentamidine, dapsone (50% cross-reactivity)

41
Q

what are the two most common causes of space-occupying lesions in the US?

A

Lymphoma and toxoplasmosis

42
Q

space-occupying lesion from brazil?

A

trypanosomiasis

43
Q

transmission of toxoplasma?

A

feline feces, rare meat (lamb>beef>Pork), congenital

44
Q

ddx of CNS mass lesions in HIV/AIDs?

A

Bacterial, lymphoma, toxoplasmosis, tuberculosis, nocardia, fungus, chagoma, kaposi, glioblastoma (BLT TNF CKG)

45
Q

what labs do you obtain in patient with CNS mass lesions/

A

Serology - Toxo igG, PCR, CrAg; blood cultures including afb, fungus; CSF CrAg, CSF PCR EBV, CMV, toxo, urine and serum histo antigen

46
Q

Empiric dx of CNS toxo?

A

Need all of the radiological findings, CD4<100, Toxo IgG antibody, response to therapy within 2 weeks.

47
Q

The preferred regimen of cerebral toxo?

A

sulfadiazine plus pyrimethamine plus leucovorin

48
Q

alternate regimens for cerebral toxo treatment?

A

bactrim OR clindamycin plus pyrimethamine or Atovaquone +/- pyrimethamine

49
Q

what are adjunctive therapies for CNS toxoplasmosis?

A

corticosteroids only if increased ICP/sympotms; anticonvulsants only after first seizure

50
Q

Indications for primary prevention of HIV toxoplasmosis?

A

positive toxoplasmosis IgG + CD4<100

51
Q

the preferred treatment of primary prevention of toxoplasmosis?

A

Bactrim Ds q daily

52
Q

alternative treatments for primary prevention of toxoplasmosis?

A

dapsone-pyrimethamine; Atovaquone + pyrimethamine

53
Q

what would you give for primary prevention of toxoplasmosis if they are already on aerosol pentamidine or dapsone for PCP prophylaxis?

A

if on dapsone, add pyrimethamine. If on aerosol pentamidine, rethink toxo options

54
Q

what are the mycobacterial infections associated with HIV infected patients?

A

BATH -GMCSX (Bovis/BCG, avium complex, tuberculosis hemophilum, genovense, malmoense, chleonei, scrofulaceum, xenopi

55
Q

which mycobacterial infections have disseminated presentations?

A

BATGS - BCG, bovis, avium complex, TB, genovense, scrofulaceum

56
Q

SSTI mycobacterial presentations in HIV?

A

chelonei (bone too), hemophilum (cutaneous abscess),

57
Q

which mycobacterial have lung presentations in HIV?

A

malmoense (cavitary lung/CNS ring lesions), Xenopi (lung nodules/infiltrates)

58
Q

what CD4/VL counts have risk factors of MAI?

A

CD4<50 or high VL

59
Q

when do you stop MAC chronic suppression?

A

CD4>100 x 6 months and therapy >12 months

60
Q

epidemiological picutre of CD4 count in patients with cryptococcal meningitis?

A

CD4<50

61
Q

Induction therapy for cryptococcal meningitis?

A

Ambisome 3-4mg/kg qd + Flucytosine 25mg/kg QID x 2 weeks. QD LP if CSF pressure>20

62
Q

Consolidtion therapy for cryptococcal meningitis?

A

Fluconazole 400mg PO qd x 8 weeks

63
Q

Maintenance therapy for cryptococcal meningitis?

A

Fluconazole 00mg PO qd >52 weeks

64
Q

Role for dexamethasone for cryptococcal meningitis?

A

None; maybe if increased ICP/ARDs

65
Q

How often would you do LPs for cryptococcal meningitis?

A

continue daily until stable for at least 2 days; shunt if daily LPs prolonged

66
Q

When do you stop therapy for cryptococcal meningitis?

A

CD4>100 x 3months with VL<50 due to ART + 12 months of cryptococcal therapy. LP optional to confirm CSf culture negative.

67
Q

what are the main CMV syndromes in HIV patients?

A

ventriculitis. colitis, Retinitis,

68
Q

CMV syndromes in HIV patients including rare?

A

VCR PEAR; Ventriculitis, Colitis, Retinitis, pneumonia, esophagitis, adrenalitis, radiculopathy

69
Q

How does CMV differ in HIV patients?

A

crosses BBB with high frequency, rarely occurs with CD4 counts >50

70
Q

what is the treatment for CMV retinitis?

A

INtravitreal ganciclovir x 4-7 doses over 1-2 weeks; IV ganciclovir or valganciclovir 900mg PO BID x 14-21 days then qD

71
Q

what is the treatment for CMV colitis?

A

Ganciclovir, valganciclovir, foscarnet

72
Q

what are the reasons for late failure for CMV therapy treatment?

A

UL97 (phosphotransferase gene) with low levels no cross resistance to foscarnet/cidofovir, many respond to high dose GCV. UL54 (polymerase gene)

73
Q

how can you tell the difference between CMV retinitis vs IRIS/IRU ?

A

uveitis has inflammation in vitreous/aqueous. Uveitis would respond to steroids

74
Q

what HIV diseases are associated with EBV?

A

oral hairy leukoplakia, CNS lymphoma, and effusion cell lymphoma

75
Q

how is the best way to think of toxoplasmosis?

A

mononucleosis without sore throat (fever/lymphadenopathy)

76
Q

common presentation of normal immunity with toxoplasmosis?

A

retinochorioiditis

77
Q

classic radiographic finding of CNS toxoplasmosis

A

single unenhanced lesion in the basal ganglia

78
Q

treatment of cryptosporidium and size/stain?

A

4 um; acid fast;ART; nitazoxanide or paraomomycin

79
Q

treatment of cyclospra and size/stain?

A

10 um;Cipro; acid fast; bactrim

80
Q

treatment of cystoisospora and size/stain?

A

20um; acid fast; Cipro, pyrimethamine; bactrim

81
Q

treatment of microsporidia and size/stain?

A

1-5 um; ART, albendazole, fumagilin

82
Q

what does microsporidia cause in immunocompetent patients?

A

self-limiting diarrhea

83
Q

what are the toxicities associated with albendazole?

A

neutropenia, CNS (dizziness), abdominal pain, hepatitis, hair loss

84
Q

what is the treatment for microsporidiosis?

A

albendazole

85
Q

what are the key HIV encephalopathies?

A

PML, HIVE, CMV

86
Q

who should receive prophylaxis against MAC?

A

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.

87
Q

what is the most common syndrome associated with IRIS?

A

MAC

88
Q

which NTM can be grown only at 32-degree centigrade with iron-enriched medium?

A

Mycobacterium haemophilum

General ID 2019 (19 decks)

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