HIV Opportunistic Infections Flashcards
1
Q
Define AIDS
A
- absolute CD4 count <200 cells/μL (CD4% <14%)
2. diagnosis of an AIDS-defining illness
2
Q
NOTE
A
25% of those with HIV do not know they have it.
3
Q
OI known to occur when CD4 count it >200? [6]
A
- TB
- Recurrent bacterial pneumonia
- Zoster
- Oral candida
- Kaposi sarcoma
- Lymphoma
4
Q
OI that usually occur once CD4 is <200? [3]
A
PML
Esophageal candia
PCP
5
Q
OI that generally occur when CD4 is <100? [3]
A
Cerebral toxo
Cryptococcosis
Miliary TB
6
Q
OI that tend to occur when CD4 is <50?
A
- MAC
2. CMV chorioretinitis
7
Q
In an HIV patient who should have an urgent opthalmologic exam?
A
- Vision loss
2. Eye pain
8
Q
Work up of eye symptoms in HIV patient? [3]
A
HSV serologies +/- PCR
Syphilis screen
Toxo IgG
May need biopsy or vitreal tap
9
Q
Ddx in patient with resp symptoms with CD4 >250? [5]
A
Bacterial pneumonia TB Coccidioides Virus Lymhpoma
10
Q
Ddx in patient with resp symptoms with CD4 <250? [5]
A
PCP Endemic fungi [histo, crypto, coccidio] Mycobacteria KS Lymphoma
11
Q
Work up of a HIV patient with low CD and resp symtpoms [8]
A
- Imaging [CXR or CT]
- Bacterial, fungal, AFB cultures of suptum and blood
- TB PCR of sputum
- PCP DFA 3x
- LDG
- ABG
- Serum cryptococcal Ag
- Urine histoplasma Ag
12
Q
Ddx og a CNS mass lesion in HIV? [7]
A
- Toxo
- PCNSL
- Nocardia
- Abscess
- Sypilitic gumma
- Chagas disease
- TB
13
Q
CSF studies to consider in meningitis patient with HIV?
A
- Fungal cultures and serologies
- Crypto Ag
- AFB cx
- TB PCR
- VDRL
- Viral PCR
14
Q
Work up of FUO in HIV patient [8]
A
Blood cultures of AFB, bacteria, fungal Crypto Ag Urine histo Ag CMV PCR HHV-8 PCR LDH Ferritin Blood smear
15
Q
When should patients with OI be started on ART?
A
within 2 weeks, excluding TB
16
Q
What OI should have ART initiation as soon as possible to promote immune recovery? [3]
A
cryptosporidiosis, microsporidiosis, PML
–> No effective treatment without immunesystem
17
Q
When should ART be started in non-meningeal TB?
A
CD4 >50: within 8 weeks
CD4 <50: within 2 weeks
18
Q
When can you d/c PCP prophylaxsis?
Toxo prophylaxsis?
A
CD4 >200 for 3 months
19
Q
Alt prophylaxsis for toxo? [2]
A
- Dapsone 200 mg + pyrimethamine 75 mg + leucovorin 25 mg) PO once weekly
- Atovaquone 1500 mg + pyrimethamine 25 mg + leucovorin 10 mg) PO daily
20
Q
When should an HIV patient be treated for LTBI?
A
- Positive screen with negative x-ray
2. close contact with person with infectious TB regardless of screening test result
21
Q
Treatment for LTBI in HIV patient?
A
- INH + pyridoxine daily
- INH + pyridoxine 2x weekly [higher dose, alt]
- Rifapentine + INH + pyridoxine weekly [alt]
22
Q
What are the live vaccines and when are they contraindicated in those with HIV?
A
measles, mumps, and rubella [MMR]; varicella; and herpes zoster
CD4 <200
23
Q
Risk factors for PCP pneumonia? [3]
A
- CD4 <200
- Hx of PCP
- Hx of oral thrush
24
Q
How does PCP sound on auscultation?
A
Diffuse dry rales
25
Classic x-ray findings of PCP?
Normal
| B/L ground glass opacities
26
What infection can lead to recurrent spontaneous pneumothoraxes?
PCP in PLWH
27
Diagnosis of PCP
1. LDH >500 is common but non-specific
2. silver, Giemsa, or direct fluorescent antibody (DFA) staining
- -> Induced sputum only has 60% sensitivity
- ->Bronchoscopy with bronchoalveolar lavage or transbronchial biopsy provides sensitivity >90%–95%.
28
What is the role of 1,3-B-D-glucan in PCP?
Elevated in PCP
| A negative test rules out PCP
29
Define mild to moderate PCP [2]
Able to take orals
| PaO2 >70 mmHg on room air
30
Define moderate to severe PCP [3]
Acutely ill, not able to take orals
PaO2 <70 mmHg on RA
A–a gradient >35 mmHg on RA
31
Treatment of mild-to-moderate PCP? [3]
1. Bactrim DS q8 for 21 days
2. Primaquine 30 mg (base) PO daily + Clindamycin 450 mg PO q6h [alt]
3. Atovaquone 750 mg PO BID
32
Treatment of mod-to-severe PCP?
1. TMP–SMX (5 mg/kg of TMP component per dose) IV q6–8h
2. Pentamidine 4 mg/kg IV daily infused over 60 min
3. Primaquine 30 mg (base) PO daily + Clindamycin 600 mg IV q6h
33
When are adjunctive steroids indicated in PCP?
PaO2<70 mmHg on RA
| A–a gradient ≥35 mmHg on RA
34
How long will it take PCP to improve?
4-8 days
| --> If no improvement by this time this is treatment failure
35
What medications should have G6PD def excluded prior to use? [2]
1. Dapsone
| 2. Primaquine
36
When should ART be started in someone dx with PCP?
Within 2 weeks
37
Two species of cryptococcus and location they occur?
Gattii: Pacific Northwest and Australia.
Neoformans: Most common, everywhere
38
Who gets cryptococcus infections?
CD4 <100
| Bird droppings exposures
39
Neuro presentation for cryptococcus?
Subacute meningoencephalitis
Fever, headache, lethargy
Progressive altered mentation
Meningismus only seen in minority.
40
What organs does disseminated cryptococcus prefer?
1. Lungs
2. Skin [like molluscum]
3. Bones
4. Prostate
41
NOTE:
If there is evidence of disseminated cryptoccus infection CNS infection must be ruled out with LP even if there are no symptoms.
42
Describe the LP findings on cryptococcus
High protein
Low to normal glucose
lymphocytic pleocytosis
Opening pressure elevated ≥25 mmHg in 60%–80% of cases.
A low or normal CSF cell count is a poor prognostic marker.
43
Management of high LP for cryptococcus?
1. Serial large-volume (25–30 mL) CSF drainage
--> steroids, mannitol, or acetazolamide are not effective.
44
Diagnosis of cryptococcus?
Cryptococcal antigen (CrAg) in blood and CSF
--> Sensitive and specific
Culture is of course gold standard
45
What are the 3 phases of cryptococcus meningitis and other extrapulmonary sites?
Induction [2 wks]
Consolidation [8 wks]
Maintenance [12 months minimum]
46
Treatment during induction phase of cryptococcus meningitis?
Liposomal amphotericin B (3–4 mg/kg per day IV) plus flucytosine (5-FC) 100 mg/kg per day PO divided over 4 doses for at least 2 weeks and until clinical improvement with negative CSF culture on repeat LP.
47
What toxicity does 5-FC cause? How is it monitored?
Bone marrow toxicity
| Goal peaks of <100 μg/mL 2 hours after dose).
48
Treatment during induction phase of cryptococcus meningitis for those intolerant of ampho B?
fluconazole 400–800 mg daily plus 5-FC may be used for 4–6 weeks.
49
Treatment during consolidation phase of cryptococcus meningitis?
Fluconazole 400 mg PO daily for 8 weeks
50
Treatment during maintence phase of cryptococcus meningitis?
Fluconazole 200 mg PO daily for at least 1 year and continued indefinitely
51
When can fluconazole be stopped for those on it for maintence in cryptococcus? [4]
1. On medication for over a year
2. CD4 >100
3. Viral load undetectable
4. On ART for 3 months or more
--> MUST MEET ALL CRITERIA
52
Treatment of mild to moderate pulmonary cryptococcus?
fluconazole 400 mg PO daily for at least 12 months.
53
When should ART be initiated in those with cryptococcal meningitis?
Between 2 and 2 weeks after antifungal therapy starts
| --> Monitor closely for IRIS
54
What is the most common OI in PLWH?
Oropharyngeal candidiasis
55
Treatment for oropharyngeal candida?
fluconazole 200 mg loading dose followed by 100 mg PO daily for 7–14 days
--> Topical antifungals are less effective in severe disease or advanced AIDS
56
Treatment of candida esophagitis?
fluconazole 400 mg loading dose followed by 200 mg PO daily for 14–21 days
57
Risk factors for coccidioidomycosis?
1. CD4 <250
| 2. Pregnancy
58
Presentation of coccidioidomycosis?
focal pneumonia in PLWH with high CD4 counts; diffuse pulmonary disease or disseminated disease [skin, bone, CNS]
59
Diagnosis of coccidioidomycosis
culture or demonstration of characteristic spherule form on histopathology.
serum or urine antigen can be useful in disseminated disease.
60
Diagnosis of coccidio in the CNS?
Complement fixation IgG serologies in the CSF
61
Treatment of coccidio pneumonia/mild disease
Oral azoles
62
Treatment of disseminated coccidio?
Amphotericin B - step down to azole
63
Treatment of coccidio meningitis?
1. CSF shunting for hydrocephalus
2. Intrathecal antifungals
3. Systemic antifungals
64
When can you stop secondary prophylaxsis for severe or meningeal coccidioidomycosis?
NEVER, regardless of CD4 counts and viral loads
| --> Relapse rate is high.
65
Who should get primary prophylaxsis for coccidio?
If all of the following are true..
1. Living in endemic area
2. CD4 <250
66
What is primary prophylaxsis for coccidio?
Fluzonazole 400 PO daily
67
What CD4 counts puts patient at increased risk for disseminated histo?
<100
68
How does progressive disseminated histoplasmosis present?
Fevers, systemic symptoms, hepatosplenomegaly, and pulmonary symptoms (50% of cases).
Less frequently, causes cutaneous, gastrointestinal (GI), or CNS involvement (subacute meningitis or brain mass) or septic shock with acute respiratory distress syndrome and/or adrenal insufficiency.
69
Does histo elevate LDH?
Yes, typically to levels >600
70
Diagnosis of histo?
Culture of blood, bone marrow, or secretions
Histoplasma antigen from blood or urine is sensitive for disseminated disease but cross reacts with other dimorphic fungi.
71
What is seen on histopathology of histoplasmosis?
2–4 μm, budding intracellular yeast forms.
72
Treatment of severe disseminated histoplasmosis?
induction with liposomal amphotericin B 3 mg/kg per day IV for 2 weeks followed by oral itraconazole 200 mg PO twice daily for at least 12 months.
73
Treatment of mild histoplasmosis?
Itraconazole
74
How long should secondary prophylaxis be continued? [5]
Until all of the following are met...
1. Minimum 1 year of antifungal therapy.
2. Negative fungal blood cultures
3. Histoplasma serum antigen <2 units.
4. CD4 >150 cells/μL
5. On suppressive ART for 6 months.
75
When should ART be started on a patient with histoplasmosis?
ASAP
| --> Histo IRIS is RARE
76
Is there primary prophylaxis for histo?
Consider itraconazole 200 mg PO daily in those with...
1. CD4 <150
2. Live in hyperendemic area OR
2. High occupational risk
77
What type of fungus is Talaromyces marneffei? [yeast? mold? dimorphic?]
Dimorphic
78
Where is Talaromyces marneffei endemic?
SE Asia
| --> Thailand, Vietnam, China
79
How does Talaromyces marneffei present?
disseminated, multiorgan disease similar to histoplasmosis with characteristic skin lesions and hepatic involvement
80
Characteristic lab finding in Talaromyces marneffei?
Elevated alk phos
81
Treatment of Talaromyces marneffe?
liposomal amphotericin B for 2 weeks followed by oral itraconazole therapy until immune reconstitution.
82
What if any prophylaxis for talaromyces should be given
Primary to those with..
CD4 <100 AND
Residence or extended visit to hyperendemic regions.
83
Risk of TB reactivation in untreated HIV?
3-16% annually
84
Presentation of TB in PLWH and CD4 >350?
classic upper lobe cavitary lung disease with fevers and constitutional symptoms.
85
Presentation fo TB in PLWH and CD4 <200?
Lower lobe disease, no cavitation, and, more commonly, extrapulmonary TB involving any organ system.
86
Common extrapulmonary sites in TB?
lymphadenitis, genitourinary tract, bone marrow, and CNS.
87
Preferred HIV regimen when treating patient with TB and why?
Efavirenz + 2 NRTIs
--> This can be used with rifampin without toxicity
Dolutegravir and raltegravir containing regimens can also be used however doses may need to be increased if used with rifampin containing TB regimens
