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nagasaki flashcard extravaganza > HIV, PEP and PREP > Flashcards

HIV, PEP and PREP Flashcards

1
Q

Window period for 4th gen test

A

Combined ab/ag -> 45 days from risk

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2
Q

Who should be offered PREP

A

MSM/TW - ongoing condomless sex
Chemsex
Detectable partner

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3
Q

What tests should be sent if seroconversion suspected

A

4th gen test plus VL

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4
Q

When is PEP recommended

A

HIV positive (detectable/unknown VL) - receptive AI, insertive AI, receptive VI, sharps, mucosal splash, sharing needles
HIV unknown but high prev group - receptive anal sex

Not recommended in any context if undetectable

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5
Q

DDx of lympadenopathy in HIV

A

HIV itself
TB
Lymphoma
Reactive (local infection or diseeminated)
NTB
Rarer infections e.g. histoplasmosis

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6
Q

What are the manifestations of cryptococcal disease?

A

Meningitis, skin lumps, pulmonary, GI

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7
Q

What is definition of primary HIV?

A

First six months following HIV acquisition

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8
Q

What HLA type is associated with abacavir hypersensitivity

A

HLA-B*57:01

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9
Q

What ART group is NOT used in HIV 2

A

NNRTI (non-nuke)

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10
Q

What are symptoms of seroconversion?

A

Fever
Lymphadenopathy
Rash
Arthralgia
Fatigue/malaise
Can be associated with meningitis
Rarely other inflammation of organs i.e. hepatitis, myo/pericarditis

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11
Q

What are indicator conditions?

A

Indicator conditions for HIV diagnosis - AIDs or est prevalance of >1/1000

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12
Q

What is increased risk of death in late presenting HIV?

A

x10

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13
Q

Which HIV meds are associated with lipoatrophy?

A

stavudine (d4T, Zerit), zidovudine (AZT, Retrovir), didanosine (ddI, Videx) and indinavir (Crixivan).

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14
Q

What is 2nd line for PCP

A

Clindamycin and primaquine (CI: if G6PD)

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15
Q

1st line for PCP

A

Co-trimoxazole, steroids
IV if hypoxic to begin with
21/7 tx

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16
Q

What week of pregnancy should women have started ART by?

A

24

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17
Q

What is a viral blip

A

a short-term increase in viral load in someone who generally maintains an undetectable viral load.

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18
Q

What is low level viraemia

A

2 or more VL > 50

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19
Q

AIDS defining malignancies

A

KS
NHL
Cervical cancer
Immunoblastic lymphoma
Primary CNS lymphoma
Burkitts

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20
Q

Risk of perinatal transmission for HIV

A

If viral load <50 then 0.1%

If unaware of status 20-35% (but may be greater if high viral load, obstetric factors and breastfeeding)

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21
Q

Risk of TB in PWLWH

A

26-31 x

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22
Q

Which NTM is associated with unpasturised milk?

A

M bovis

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23
Q

What are the stages of TB

A

Primary TB
Progressive primary TB
Latent TB
Post-primary TB (= reactivation)

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24
Q

When is TB treatment > six months

A

Resistance
CNS
Pericarditis
Steroid use

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25
Q

When is ART started if TB diagnosed beforehand?

A

CD4 <50 within two weeks
CD4 >50 within 8-12 weeks
TBM = after 8 weeks

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26
Q

Criteria for latent TB

A

Absence of clinical signs or symptoms of active TB, including a normal chest x-ray
Evidence of TB infection - IGRA only for HIV, can use TST in non-HIV

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27
Q

When can septrin prophylaxis be discontinued?

A

CD4 >200 for 3 months and low/UD VL

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28
Q

Treatment for oropharyngeal candida in HIV

A

Fluconazole 100–200 mg once
daily 7-14 days

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29
Q

Treatment for oesophageal candidiasis in HIV

A

Fluconazole 200–400 mg once
daily for 14-21 days

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30
Q

Commonest side effects of TDF

A

Bone density loss
Renal dysfunction
Proteinuria

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31
Q

What class of ART are raltegravir, doluetegravir, bictegravir, elvitegravir

A

Integrase inhibitor

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32
Q

Which NNRTI is associated with HLA 5701 hypersensitivity

A

Abacavir (this is in Kivexa and Triumeq)

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33
Q

Which class of ART are darunavir, atazanavir?

A

Protease inhibitors

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34
Q

What are the boosters used with PIs?

A

Ritonavir, cobicistat

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35
Q

Which booster is not used in pregnancy

A

Cobicistat

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36
Q

Common side effects of TAF

A

Lipidaemia
Weight gain

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37
Q

Commonest side effects of integrase inhibitors?

A

Weight gain
Low mood
Anxiety
Sleep disturbance

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38
Q

Which HIV meds are associated with weight gain?

A

TAF
Dolutegrvair
Bictegravir

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39
Q

What is the commonest DDI with rilpivirine?

A

With PPI or anything affecting gastric acid secretion (pH dependent - why you take it with food)

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40
Q

Which ART is associated with non cirrhotic portal htn

A

Didanosine

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41
Q

Which HIV drug is used in ATLL?

A

AZT

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42
Q

What is the injectable ART regime currently licensed in UK? How often are they given?

A

Cabotegravir/Rilpivirine
1-2 monthly

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43
Q

Which trial demonstrated U=U

A

PARTNER

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44
Q

Which trial influenced when we started initiating ART early in HIV?

A

START

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45
Q

How is cryptococcal meningitis tested for?

A

Serum then CSF antigen
Culture (gold standard) - prolonged as it is fungal
India Ink Stain

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46
Q

What causes a ‘pizza’ appearance to the retina in HIV

A

CMV

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47
Q

Name 4 conditions which can cause enhancing intracranial lesions in advanced HIV?

A

Toxoplasma (esp multiple)
Tuberculoma
Cryptococcoma
Lymphoma

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48
Q

How is PCP treated?

A

Cotrimoxazole (+steroids if hypoxic)
2nd line clindamycin and primaquine

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49
Q

What is used for PCP prophylaxis

A

Cotrimoxazole
If unable-> dapsone
If unable -> pentamidime (nebulised)

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50
Q

What is the increased lymphoma risk in PLWHIV?

A

A person with HIV is 10 to 20 times more likely to develop non-Hodgkin lymphoma and about 8 times more likely to develop Hodgkin lymphoma than a person without HIV

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51
Q

Name 3 HHV8 associated malignancies?

A

Kaposi’s Sarcoma
Castleman’s
Primary Effusion Lymphoma

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52
Q

What is HHV - 4

A

EBV

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53
Q

What is HHV 3

A

Varicella

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54
Q

What is HHV 5

A

CMV

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55
Q

What is HHV 1 and 2

A

HSV 1 and 2

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56
Q

Name 2 EBV/HHV4 associated cancers?

A

Hodgkin’s
Burkitts

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57
Q

Causative virus in oral hairy leukoplakia?

A

EBV/HHV4

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58
Q

Which ART interacts with CHC

A

Nevirapine, Efavirenz, PIs

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59
Q

Which ART needs an induction dose and is associated with hepatitis?

A

Nevirapine

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60
Q

What are the SEs of efavirenz?

A

CNS disturbance (irritability, sleep dis)
Raised lipids
Gynaecomastia

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61
Q

What ART raises lipids

A

PIs
TAF
Integrase
Efavirenz

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62
Q

Which organism cause PML?

A

JC virus

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63
Q

What are the symptoms of PML?

A

Cognitive or affective change, ataxia, weakness, visual change

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64
Q

What is the treatment for PML?

A

ART - nil evidence for anything else
May progress even with intensive ART

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65
Q

How is PML diagnosed

A

MRI
JC virus on CSF (may be negative)
Brain biopsy where uncertainty

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66
Q

What is PML?

A

Progressive multifocal leukoencephalopathy

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67
Q

How is CMV managed

A

Treatment course of valgiclovir, ganciclovir
Prophylaxis not routinely used

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68
Q

Commonest site for CMV disease in advanced HIV?

A

Eyes (75%)
Other sites: gut, spleen, liver, CNS eg encephalitis

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69
Q

At what CD4 count does CMV become likely?

A

<50

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70
Q

Why do we test G6PD in HIV patients?

A

Precludes use of certain drugs eg dapsone and high dose septrin

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71
Q

What are the common eye problems in advanced HIV?

A

CMV
HSV
HIV vasculopathy
Toxoplasmosis

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72
Q

What liver problem is described in relation to cryptosporidia and microsporidia?

A

Sclerosing cholangitis (would see on ERCP)

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73
Q

How is microsporidium managed?

A

ART
Supportive
Anti parasite tx - eg fumagillan, albendazole

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74
Q

What is increased in NHL in HIV

A

Systemic high grade B-cell NHL occurs 60-100 times more frequently in people with HIV than in the matched general population.

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75
Q

How is HHV8 transmitted?

A

Saliva

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76
Q

What chemo is used for disseminated KS?

A

Anthracyclines

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77
Q

How much more common is cancer in HIV than general population?

A

2-3

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78
Q

Complications of KS

A

GI bleeding
Lymphodema
Visceral involvement including pulmonary

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79
Q

What are the AIDs-defining malignancies?

A

Cervical Cancer
NHL
KS
Immunoblastic lymphoma
Primary CNS lymphoma
Burkitts

80
Q

What are the AIDs defining bacterial infections?

A

2 x pneumonia in 12 months
Salmonella Septicimia
TB
NTM
MAC

81
Q

What are the AIDs-defining viruses?

A

Cytomegalovirus disease (other than liver, spleen or lymph nodes)
Cytomegalovirus retinitis (with loss of vision)
Herpes simplex: chronic ulcer(s) (for more than 1 month); or bronchitis, pneumonitis, or esophagitis
Progressive multifocal leukoencephalopathy (JC)

82
Q

What are the AIDs defining fungi?

A

Histoplasmosis, disseminated or extrapulmonary
Pneumocystis jirovecii pneumonia (formerly Pneumocystis carinii)
Cryptoccocus
Candidiasis of oesophagus, lung

83
Q

What are the AIDs defining parasites?

A

Cerebral toxo
Cryptosporidosis
Reactivated sleeping sickness
Isosporiasis, chronic intestinal (for more than 1 month)

84
Q

What are the HIV related AID’s defining illnesses?

A

HIV encephalopathy
HIV wasting syndrome

85
Q

what is the target of maraviroc

A

CCR5
Entry inhibitor

86
Q

Risk of HIV transmission via breastfeeding?

A

PROMISE trial
0.3-0.7% - higher over time

87
Q

What do 3rd generation HIV tests test for

A

HIV antibody only

88
Q

If a patient is on ART for HIV which medications also suppress Hep B

A

Lamivudine
Emtricitabine
Tenofovir DF
Tenofovir AF

89
Q

In what situation may there be a false negative HIV test?

A

A test can be falsely negative very early in the window period
e.g. If a high risk HIV exposure occurred in the previous 4-6 weeks s

A negative test with a 4th generation (antigen + antibody test) EIA at 4 weeks excludes HIV infection with a high degree of certainty.

PREP

(a few cases described of prolonged seroconversion, usually with simultaneous other viral illness)

90
Q

what is an equivocal or indeterminate HIV test?

A

An equivocal / indeterminate tests = a positive screening test which is negative when tested by a second and third serological test.

Can be BFP or too early in seroconversion

Management - repeat test

91
Q

HIV prevention strategies

A

Condom use
PEPSE
Serosorting/stategic positioning - mixed data
PREP
Male circumcision - data from Africa suggests MC protects heterosexual men from acquiring HIV
Reduce the number of partners

92
Q

How may being HIV +ve affect the presentation of STS

A

Some minor differences syphiis presentation in HIV +ve patients include:

primary syphilis- up to 70% present with >1 chancre + larger / deeper lesions
25% present with concomitant lesions of primary and secondary stages at presentation
atypical and severe presentations of syphilis occur more frequently (still a v small minority)
Syphilis can cause transient increase in the viral load and decrease in the CD4 cell count - resolve after treatment

93
Q

What was the ACTG 5164 study and what did it show?

A

ACTG 5164 study
demonstrated fewer AIDS progressions/deaths
And improved cost-effectiveness

when ART was commenced within 14 days treatment for acute infection (e.g. PCP)
Rather than ART initiation at the completion of antibiotic treatment

94
Q

what is Cobicistat inhibitor of ?

A

Cobicistat is an inhibitor of CYP3A isozymes

Used as a pharmacokinetic booster of other antiretroviral drugs
Alternative to ritonavir- boosted PI

95
Q

Definition of incomplete virological response

A

Incomplete virological response = 2 consecutive VL >200 after 24 weeks
without ever achieving VL <50

96
Q

Definition of Low-level viraemia

A

Low-level viraemia = a persistent VL between 50–200

97
Q

when should neonatal PEP should be commenced?

A

As soon as possible after birth

At least within 4 hours

98
Q

Management of toxoplasmosis

A

Sulfadiazine and pyrimethamine

99
Q

worldwide what % of HIV is transmitted by IVDU

A

1 in 10 new diagnoses worldwide due to IVDU

100
Q

Factors increasing the risk of HIV transmission

A

High viral load of the source
breaches in the mucosal barrier - ulcers / trauma
menstruation / other bleeding (theoretical)
other STI in a HIV +ve pt not on ARVs
Ejaculation
Non-cicumcision
discordant VL in the genital tract

101
Q

Calculation for estimating the risk of HIV transmission

A

Risk of HIV transmission = risk source is HIV +ve X risk per exposure

e. g. Manchester MSM = x receptive anal intercourse with ejaculation
8. 6. / 100 X 1/65 = 1 / 757

102
Q

Rationale behind PEPSE

A

window of opportunity to avert HIV infection
inhibiting viral replication following exposure

HIV crosses a mucosal barrier
takes 48–72 h before HIV detected in regional lymph nodes
take 5 days before HIV detected in blood

Animal models = Initiation of ART reduces dissemination + replication of virus in all tissues if initiated early after inoculation

103
Q

In what circumstance would PEPSE be recommend when the source is known HIV positive with an undetectable VL

A

Source does not have a confirmed VL < 200 for >6 months

104
Q

When is U=U considered?

A

VL = <200 for six months, on treatment

105
Q

Differential for chest infection in HIV

A

Bacterial - any inc pneumoccocus, TB, NTM
Viral - flu, HSV
Fungal - PCP, cryptococcus

106
Q

What is the preferred WHO regime for PEP?

A

TDF + 3TC or FTC + Dolutegravir

107
Q

How often are stable patient with HIV monitored?

A

6-12 months

108
Q

What art is preferred in renal impairment?

A

TDF>TAF
May need to avoid integrase
2 drug regimes good if no resistance/adherence concerns

109
Q

What is transmitted resistance in HIV?

A

Drug resistance in ART-naive patient
Mostly commonly NNRTI
May disappear the longer someone has HIV untreated (reversion to wild type)

110
Q

What are the complications of PCP?

A

ARDS/resp failure
Cyst formation
Pneumothorax
Drug related side effects - renal failure, haemoylsis, drug psychosis
Permanent lung damage - scarring

111
Q

What is allergy to darunavir associated with?

A

Sulfa allergy
Usually presents as a widespread rash

112
Q

Can women with HIV have VBAC?

A

Yes if VL <50

113
Q

Causes of hepatosplenomegaly in HIV?

A

Chronic liver disease (acute usually just hepatomegaly)
Lymphoma
HIV usually just causes splenomegaly

DDx in general leismania, lymphoma/MPN, EMV, CMV

114
Q

What CD4 do you not give live vaccines below

A

200
Chickenpox, shingles, yellow fever (TB)

115
Q

Which subtype associated with increased perinatal transmission?

A

Subtype C associated with increased MTCT
Plus: VL, CD4, PROM, chorioamionitis, STIs, cracked nipples, breast abscess

116
Q

What is clinical stage 1 in HIV?

A

Asymptomatic
Persistent generalized lymphadenopathy

117
Q

What is clinical stage 2 in HIV?

A

Moderate unexplained weight loss (<10% of presumed or measured body weight)
Recurrent respiratory tract infections (sinusitis, tonsillitis, otitis media, pharyngitis)
Herpes zoster
Angular cheilitis
Recurrent oral ulceration
Papular pruritic eruption
Fungal nail infections
Seborrhoeic dermatitis

118
Q

What is clinical stage 3 in HIV?

A

Unexplained severe weight loss (>10% of presumed or measured body weight)
Unexplained chronic diarrhoea for longer than 1 month
Unexplained persistent fever (intermittent or constant for longer than 1 month)
Persistent oral candidiasis (in children - after 6 weeks of life)
Oral hairy leukoplakia
Pulmonary tuberculosis
Severe bacterial infections (such as pneumonia, empyema, pyomyositis, bone or joint infection, meningitis, bacteraemia)
Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
Unexplained anaemia (<8 g/dl), neutropaenia (<0.5 × 109/L) and/or chronic thrombocytopaenia (<50 × 109/L)

119
Q

What is clinical stage 4 in HIV?

A

HIV wasting syndrome
Pneumocystis (jirovecii) pneumonia
Recurrent severe bacterial pneumonia
Chronic herpes simplex infection (orolabial, genital or anorectal of more than one month in duration or visceral at any site)
Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs)
Extrapulmonary tuberculosis
Kaposi sarcoma
Cytomegalovirus infection (retinitis or infection of other organs)
Central nervous system toxoplasmosis
HIV encephalopathy
Extrapulmonary cryptococcosis, including meningitis
Disseminated nontuberculous mycobacterial infection
Progressive multifocal leukoencephalopathy
Chronic cryptosporidiosis
Chronic isosporiasis
Disseminated mycosis (extrapulmonary histoplasmosis, coccidioidomycosis)
Lymphoma (cerebral or B-cell non-Hodgkin)
Symptomatic HIV-associated nephropathy or cardiomyopathy
Recurrent septicaemia (including nontyphoidal Salmonella)
Invasive cervical carcinoma
Atypical disseminated leishmaniasis

120
Q
A
121
Q

What are the 3 main types of HIV tests? (3)

A
  1. Antibody tests
  2. Antigen antibody tests
  3. NATs (nucleic acid tests) or PCR
122
Q

What are the advantages and disadvantages of antibody tests for HIV?

A
  • Can take 23-90 days to detect HIV antibodies.
  • Results 5-10 days
123
Q

What are the advantages and disadvantages of antigen/antibody test for HIV?

A
  • p24 antigen produced before antibodies develop thus earlier detection 18-45 days
  • in general note blood from vein better than skin prick etc
  • can do rapid test 20 min
124
Q

What is the issue of doing HIV serological tests on newborns?

A

HIV specific maternal antibodies cross placenta. Can have maternal antibodies up to 18m even if uninfected.
Need PCR

125
Q

What are the advantages and disadvantages of HIV PCR testing?

A
  • Look for actual virus in blood
  • Good for people recent exposure and early sx of HIV with neg antigen/antibody test
  • a NAT detect HIV 10-33 days post exposure
  • Difficult in low resource settings!!!
126
Q

What is the western blot test?

A

Can be used confirm an HIV diagnosis.
Detects HIV ANTIBODIES.

127
Q

Describe the ELISA test in the context of HIV

A

Enzyme linked immunosorbent assay - detects ANTIBODIES.

Very accurate when combined with western blot

128
Q

What is stage 1 HIV? (3)

A

Acute HIV infection

  • Sore throat
  • Maculopapular rash
  • Persistant lymphadenopathy
129
Q

What is involved in stage 2 HIV? (general points no specific diseases) (3)

A
  • Moderate unexplained weight loss (<10%)
  • Recurrent URTIs, sinusitis, tonsilitis, otitis media, pharyngitis
  • Various conditions affecting skin, nails, mucous membranes
130
Q

What stage of HIV - papular pruritic eruptions?

A

Stage 2

131
Q

What stage of HIV - Herpes zoster/complications?

A

Stage 2

132
Q

What stage of HIV - Seborrhoeic dermatitis?

A

Stage 2

Treat with ketoconozole - improves on ART

133
Q

What is the treatment for localised (dermatomal HSV)

A

Acyclovir 800mg 5x day for 7-10 days

Other - Valacyclovir/famcyclovir

134
Q

What stage of HIV - fungal nail infections?

A

Stage 2

135
Q

What stage of HIV - oral hairy leukoplakia?

A

Stage 3

EBV associated - membranes cannot be scraped off –> improves on ART

136
Q

What stage of HIV? Oral candidiasis and oesophageal candidiasis?

A

Stage 3
Stage 4

Oral anti fungal - Fluconazole

137
Q

What stage of HIV? Pulmonary TB

A

Stage 3

Note as CD4 count drops - less likely to see granulomas as very limited immune response.

138
Q

What stage of HIV - disseminated TB?

A

Stage 4

139
Q

Describe the clinical picture of Tb in high CD4 count HIV?
a) symptoms
b) Imaging
c) sputum smear
d) Extra-pulmonary involvement?

A

a) severe cough + haemoptyiss
b) cavities - particularly upper lobe
c) positive
d) rare <20%

140
Q

Describe the clinical picture of Tb in low CD4 count HIV?
a) symptoms
b) Imaging
c) sputum smear
d) Extra-pulmonary involvement?

A

a) minimal cough ,rare hamoptysis
b) No cavities - hilarious lymphadenopathy, miliary pattern - can be normal
c) often negative
d) common >50% disseminated disease

141
Q

Describe what conditions are in WHO stage 3 (general themes, not specific diseases)? (5)

A
  1. Severe weight loss
  2. Chronic diarrhoea ( >1 month)
  3. Persistent fever (intermittent or constant for >1 month)
  4. Severe bacterial infections
  5. Unexplained aanemia +/- chronic thrombocytopenia (plus <50)
142
Q

What is the viral cause of kaposis sarcoma?

A

HHV8

Human Herpesvirus-8

143
Q

What stage of HIV is kaposis sarcoma?

A

stage 4 - AIDS defining

144
Q

What is the treatment of kaposis sarcoma?

A

Mainstay - ART and analgesia

Consider chemo - mucosal/internal organ involvement, nodular involvement, assoc oedema, kids

Tricky - chemo in rural sub saharan Africa??

145
Q

Give some examples of kaposis sarcoma supportive care? (4)

A

Analgesia

Topical salycic acid - itching

Crushed metronidazole to reduce smell

K+ permanganate to dry excess oozing

146
Q

What stage of HIV - Pnumocystitis jirovecii pneumonia?

A

stage 4

Most common AIDS defining condition in UK/USA

147
Q

What is the serum B glucan test and its use in PJP?

A

Detects fungal antigens in bodily fluid

High levels suggest PJP

148
Q

PJP work up in low resource setting? (one key diagnostic test) (3)

A
  1. O2 desaturated test
  2. CXR
  3. Blood tests - Investigations for HIV and Tb
  4. Low threshold for TB tx if unsure
149
Q

Treatment for pneumocystitis jirovecci?

A

Co trimoxazole IV or PO for 21/7

Severe cases IV plus pred

CPT - lifelong co-trimox preventative therapy

150
Q

What is the most common form of adult meningitis in Southern Africa?

A

Cryptococcal meningitis

151
Q

What stage of HIV - cryptococcal meningitis?

A

Stage 4

152
Q

Syndromic diagnosis - HIV +ve, CN6 palsy, headache?

A

Cryptococcal meningitis

ddx Tb meningitis

153
Q

What are the 3 phases of treatment in cryptococcal meningitis (general phases)

A
  1. Induction Phase
  2. Consolidation phase
  3. Maintenance Phase
154
Q

What is the treatment guideline of cryptococcal meningitis in resource rich settings?

A

2 weeks Amp B and Flucytosin
8 weeks Fluconazole high dose
12 weeks Fluconozole normal dose

155
Q

What is the treatment guideline of cryptococcal meningitis in a resource poor setting?

A

Lip Amp B (stat) + Flucytosin + Fluconozole 2 weeks
Fluconozole high dose 8 weeks
Normal dose fluconazole 12 weeks

WHO guidelines - until CD4 over 200 and viral loads supressed

156
Q

When should you start ART in new HIV diagnosis and cryptococcal meningitis and why?

A

After 4-6 weeks
Risk of IRIS

As per WHO guidelines
Management of CM in HIV

157
Q

What is IRIS in the context of HIV?

A

Immune reconstitution inflammatory syndrome

158
Q

What are environmental risk factors for Talaromycosis?

A
  1. Areas of high rainfall
  2. The bamboo rat (only known animal reservoir)
  3. Endemic in Asia only
159
Q

What is the treatment for Tararomycosis

A

Antifungal Tx

(Lip) Amp B 2 weeks
Itraconizole/voriconozole 10-12 weeks

160
Q

What is someones CD4 count likely to be if you diagnose Talaromycosis?

A

Less than 100

161
Q

What is the causative organism in Talaromycosis?

A

Talaromyces Marneffei - a dimorphic fungus

162
Q

Do steroids have a role in the management of cryptococcal meningitis?

A

No. Charlie’s paper

163
Q

Give differentials for SOL in HIV?

A

Pyogenic abcess
Cryptococcoma
Tuberculoma
Cerebral Toxoplasmosis
PML (progressive multifocal leukoencephalopathy
Primary CNS Lymphoma

164
Q

Spot diagnosis:
Low CD4 count, CNS symptoms, ‘multiple ring enhancing lesions’ on CTB

A

Cerebral Toxoplasmosis

165
Q

What is PML?

A

Progressive multifocal leuoencephalopathy

Severe demyelination disorder

Often insidious onset and progression of symptoms

Caused by a virus infection (polyomavirus JC)

  • preferentially affects the CNS
  • pathophysiology - reactivation due to poor immune system of HIV
  • subacute focal neurology
166
Q

What causes PML?

A

JC virus - Polyomavirus
Reactivation when CD4 is <200

167
Q

What is the treatment for PML?

A

Antiretroviral treatment

168
Q

What is the treatment for cerebral toxoplasmosis?

A

Pyrimethamine + sulfadiazine + folinic acid or cotrimoxazole

169
Q

What is the general treatment concept for HIV? (what is the usual combination)

A

NRTI + NRTI + INSTI/NNRTI/PI

Nuke backbone plus different class

170
Q

What is WHO preferred first line antiviral therapy for HIV-1?

A

NRTI +NRTI +Insti
Tenofovir + Lamivudine or Emitriciatibine + Dolutegravir

One pill a day

171
Q

Name 4 NRTIs?

A

TENOFOVIR (TDF/TAF)
Lamivudine (3TC)
Emtricitabine (FTC)
Abacavir (ABC)

Ziovudine (AZT) - Dallas buyers club

172
Q

In addition to HIV, what do Tenofovir, Lamivudine and Emtricitabine also have action against?

A

Hep B

173
Q

What are the most important side effects of Tenofovir? (2)

A

Nephrotoxic - tubular damage

Reduction in bone mineral density

174
Q

Explain why febrile hypersensitivity reaction in Caucasian person taking Abacavir (ABC)?

A

HLA b5701

Very rare in Africans

175
Q

What is the main use of ABC in HIV?

A

Infants and children (ABC +3TC = backbone)

Adults if other regimens fail/not tolerated

176
Q

What is the main issue with AZT?

A

Macrocytic anaemia particularly in Africa

Also BD dosing

177
Q

What is the main use of AZT in HIV treatment today?

A

Infant prophylaxis

178
Q

Name two intergrase (strand transfer) inhibitors?

A

DOUTEGRAVIR (DTG)
Raltergravir

179
Q

List some of the advantages of using Dolutegravir?

A

RAPID VIRAL SUPRESSION
Low interactions
Low cost
Safe and effective in TB co-infected patients

Safe in kids
Affective against HIV-2

180
Q

What are the side effects of Dolutegravir (DTG)?

A

Weight gain
Sleep disturbances
Dizziness
Paraesthesias
Hyperglycaemia

NTD ?? informed decision making

181
Q

Name 2 NNRTIs?

A

Nevirapine
Efavirenz

182
Q

A patient starts on ART and develops gynaecomastia - what drug are they likely on?

A

Efavirenz

183
Q

What are the two most important side effects of Nevirapine?

A

Rash - Stevens Johnsons Syndrome
Hepatotoxicity

184
Q

Name 3 protease inhibitors?

A

Darunavir-r
Atazanavir-r
Lopinavir-r

185
Q

What are the main issues with PI and why they are no longer commonly used as first line?

A
  1. High pill burden
  2. Side effects - including lipodystrophy
  3. Multiple interactions - CYP450
186
Q

According to WHO how long after commencement of treatment should someone be undetectable?

A

6 months

187
Q

What is the viral copies/ml to be undetectable?

A

50 copies per ml

188
Q

What is the reasoning behind cotrimoxazole preventative therapy? (5)

A

Prophylaxis from
1. PJP
2. Cerebral toxoplasmosis
3. Intestinal Protozoa
4. Gram -ve sepsis (invasive non typhoidal salmonella)
5. Malaria (partial protection)

189
Q

Define IRS and types

A

immune reconstitution inflammatory syndrome

Unmasking IRIS - west undetected OI starts manifesting after starting ART

Paradoxical IRIS - known OI (on treatment) deteriorates after ART start

190
Q

What is PREP?

A

Pre exposure prophylaxis of HIV (taken by negative patients)

191
Q

What is oral PrEP composed of?

A

Usually 2 ARVs usually TDF/FTC - usually Truvada

192
Q

What is Cabotegravir and its relationship with PREP?

A

long acting injectable intergrase inhibitor - injection every 8 week

193
Q

Prevention of mother to child transmission of HIV?

A
  1. Mum on ART
  2. C section*
  3. Infant prophylaxis
  4. avoid breastfeeding*

Not used in most African countries - debated elsewhere especially if undetectable

194
Q

Treatment for high risk infant prophylaxis in HIV

A

AZT and NVP for 6 weeks, if breastfed for another 6 weeks

195
Q

Treament for prophylaxis low risk kids (mum on ART)

A

6 weeks of NVP

196
Q

What is the global coverage of ART for children

A

20-60%, rising with age

197
Q

What does darunavir inhibit?

A

Darunavir is metabolized by and inhibits cytochrome P-450 (CYP) isoenzyme 3A4 - why there are lots of DDIs

nagasaki flashcard extravaganza (34 decks)

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