HIV + syphilis Flashcards
HIV diagnosis - protocol
Presumptive diagnosis made with ELISA –> positive results are then confirmed with Western blot assay
HIV - ELISA/Western blot test - disadvantages
- falsely negative in the fist 1-2 months of HIV infection
2. falsely positive in babies born to infected mothers (anti-gp120 crosses placenta)
how to diagnose HIV in infants younger than 18 months (no antibodies production) born to seropositive mothers
p24 antigen test
PCR
viral culture (not common)
AIDS diagnosis?
- less than 200 CD4+ cells/mm3
- HIV+ with AIDS-defining conditions
- CD4 percentage less than 14%
normal CD4 COUNT
500-1500 cells/mm3
HIV - disease (and pathogen) IF CD4 lower than 500
- oral thrush - Candida ablicans
- Oral hairy leukoplakia (EBV)
- Kaposi sarcoma (HHV-8) (?????)
- SCC, commonly of anus (men who have sex with men, or cervix (HPV)
HIV - disease (and pathogen) IF CD4 lower than 200
- dementia (HIV)
- Progressive multifocal leukoencephalopathy (JC)
- Pneumocystic pneumonia (Pneumocystis jirovecii)
- Histoplasma capsulamtum
Progressive multifocal leukoencephalopathy (JC) findings
Non-enhancing areas of demyelination on MRI
HIV - disease (and pathogen) IF CD4 lower than 100
- Hemoptysis, pleuritic pain (Aspergilus)
- Meningitis (Cryptococcus neoformans)
- esophagitis (Candida)
- Retinitis, esophagitis, colitis, pneumonitis, encephalitis (CMV)
- B-cell lymphoma (non-Hodgkin, CNS) (EBV)
- Fever, weight loss, fatique, cough, dyspnea, nausea, vomiting, diarrhea (Histoplasma)
- Nonspecific systemic infection (fever, nigh sweats, weight loss) or focal lymphadenitis (M. avium-intracellulare)
- Brain abscesses (Toxoplasma gondi)
HIV - Hemoptysis, pleuritic pain (Aspergilus) - findings
cavitation or infiltrates on chest imaging
prophylaxis in HIV patients
less than 200: TMP-SMX (PCP)
less than 100: TMP-SXM (PCP + Toxo)
less than 50: azythromycin or clarythromycin (Myc avium)H
- acyclovir only if frequent reccurence of HIV regardless CD4
HIV patients are at risk for toxoplasmosis when … / prophylaxis
CD4 less than 100
- if positive serology (for latent infection) and less than 100 –> TMP/SXM –> can discontinue when more than 200 for 3 months
TB in HIV - prophylaxis
isoniazid if (+) skin test or contact with active person
Approach to odynophagia + dysphagia in patients with HIV
suspected esophagitis
- if mild symptoms + orla thursh –> candida (fluconazol) –> endoscopy if no improvement
- Severe without thursh –> endoscopy:
- white plaques –> fluconazole
- linear ulcers –> ganciclovir (CMV)
- vesicles and round/ovoid ulcers –> acyclovir (HSV)
- apthous ulcers –> symptomatic therapy
viral vs fungal esophagitis in HIV
- fungal: oral thrush
2. viral: severe odynophagia (pain) without dysphagia (difficulty) or thrush
Common causes of esophagitis in HIV
- Candida (MC): white plagues, oral thrush
- HSV: herpetic vesicles + round/ovoid ulcers, concurrent perioral/oral HSV
- CMV: deep LINEAR ulcers, Distal esophagus
- Idiopathic/aphthous: concurrent oral aphthous ulcers
Progresive multifocal leukoencephalopathy - diagnosis / treatment / how many CD4 in HIV
- CT brain: white matter lesions with no enhancement or edema
- LP: CSF PCR for JC virus
- Brain biopsy (rarely)
treatment: often fatal / if HIV: antiretroviral therapy
- less than 200 CD4
acute HIV infection - epidimiology
2-4 wks after exposure
acute hiv infection - clinical features
- Mono-like syndrome (fever, lymphadenopathym sore throat, arthralgias
- generalised macular rash
- GI symptoms
infectious mono causes a febrile illness, closely resemble to 1ry HIV infection - the key distinctions are
- rash + diarrhea are less common in IM
- exudative pharyngitis is uncommon in 1ry HIV
acute HIV infection - diagnosis
- viral load is elevated
- HIV antibody are (-)
- normal CD4
clinical features in HIV in infancy
- failure to thrive
- chronic diarrhea
- Lymphadenopathy
- PCP
asymptomatic at birth
NORMAL COUNT OF CD4
postexposure prophylaxis to HIV
3 drug antiretrovial therapy for 4 weeks for high risk occupational exposure to blood or body fluids
- 2 nucleotide/nucleoside reverse transcriptase inj PLUS integrase inh or protease inh or non-nucleoside reverse transcriptase inh
high risk contact HIV (prophylaxis recommended) - exposure of / to
- mucus membrane, nonintact skin, percutaneous exposure
- blood, semen, vaginal secretions ,any body fluid with visible blood
- uncertain risk: CSF, pleural/pericardial fluid, synovial fluid, peritoneal fluid, anmiotic fluid
low risk contact HIV (prophylaxis NOT recommended) - exposure
urine fecees, nasal, saliva, sweat, tears (with no visible blood)
bacillary angiomatosis
bright red, firm, friable exophytic nodules in HIV patient
- caused by Bartonella
common causes of diarrhea in patients with AIDS - CD4 count - bloody?
Cryptosporidium - less than 180
Microsporidiumi/isosporidium: less than 100
Mycobacterium avium complex: less than 50
CMV: less than 50 - THE ONLY WITH BLOOD
AIDS - cryptosporidium diarrhea: CD4 + manifestation
- less than 180
- low grade fever
- weight loss
- severe watery
AIDS - microsporidium diarrhea: CD4 + maniefestation
- less tan 100
- watery, crampy abd pain
- Fever is rare
AIDS - Mycobacterium avium diarrhea: CD4 + manifestation
- less than 50
- watery
- weight loss
- high fever
AIDS - CMV diarrhea: CD4 + manifestation
- less than 50
- frequent, small volume diarrhea
- hematochezia
- abd pain
- low grade fever
- weight loss
initial screening for HIV - who
- age 15-65 (+ younger or older if at risk)
- TREATMENT FOR TB
- Treatment for another STD
annular (or more frequent) screening for HIV - who
- IV + sex partners
- men sex men
- Sex for money or drugs
- partner of HIV (+)
- patient or panter has had more than 1 partner since last HIV test
- homeless shelter living
- cirrectional facility incarceration
HIV additional screening
- pregnancy
- occupational exposure to blood/body fluids
- any new STD symptoms
- Suggested: prior to any new sexual relationship
vaccines for adults with HIV
- HBV
- HAV: chronic liver disease, men sex men, IV drugs
- HPV if 11-26
- influenza: inactivated, annually
- Mening: all
- Pneumonioc: PCV13 once, PPSV23 8 ks later, 5 yyears later + at age 65
- Tdap as needed and each pregnancy
varicella vaccination in HIV
only if CD4 more than 200 and LOW TITERS of virus
watery diarrhea in AIDS - best initial test
culture, ova, parasites, acid fast stain, C. difficile antigen
HIV therpay - groups of drugs
- protease inhibitors
- Nucleoside Reverse Transcriptase Inhibitor (NRTI)
- Non-nucleoside reverse transcriptase inhibitors (NNRTI)
- Integrase inhibitors
- Fusion inhibitors
HAART regimen consist of
2NRTIs (Nucleoside Reverse Transcriptase Inhibitor) and 1 of the following: NNRT1 (Non-nucleoside reverse transcriptase inhibitors) or protease inhibitor or integrase inhibitor
Protease inhibitors - drugs
-NAVIR
HIV-1 Protease in encoded by / function
- pol gene
- assembly of virions depend on HIV-1 protease, which cleaves the polypeptide products of HIV mrna into theri functional parts
HIV Protease inhibitors - toxicity
- hyperglycemia
- GI tolerance (nausea, vomiting)
- Lipodystrophy (Cushing-like syndrome)
- Nephropathy (indinavir)
- hematuria (indinavir)
- inhibit cytochrome P-450 (ritonavir)
HIV protease inhibitors with antimycobacterial drugs
Rifampin (a potent CYP/UGT inducer) contraindicated with proteae inhibitors because it can decrease protease inhibitor concentration
Nucleoside Reverse Transcriptase Inhibitors (NRTIs) - mechansim of action
Competitively inhibit nucleotide binding to reverse transcriptase and terminate the DNA chain (Lack of OH group
Nucleoside Reverse Transcriptase Inhibitors (NRTIs) - drugs
- Abacavir (ABC)
- Didanosine (ddl)
- Emtricitabine (FTC)
- Lamivudine (3TC)
- Stavudine (d4T)
- Tenofovir (TDF)
- Zidovudine (ZDV, formerly AZT)
Nucleoside Reverse Transcriptase Inhibitors (NRTIs) - structure
Tenofovir –> nucleotide
the others –> nucleosides and need to be phosphorylated to be active
Nucleoside Reverse Transcriptase Inhibitors (NRTIs) - side effects
- Bone marrow suppression
- peripheral neuropathy
- lactic acidosis (nucleosides)
- anemia (ZDV)
- pancreatitis (didanosine)
Non-nucleoside reverse transcriptase inhibitors (NNRTI) - drugs and mechanism of action
- Delavirdine 2. Efavirenz 3. Nevirapine
Bind to reverse transcriptase at site different from NRTIs. Do not require phosphorylation to be active or compete with nucleotide
Non-nucleoside reverse transcriptase inhibitors (NNRTI) - toxicity
- rash
- hepatotoxicity
- vivid dreams (efavirenz)
- CNS sympoms (efavirenz)
- contraindicated in pregnancy (Delavirdine and efavirenz)
Non-nucleoside reverse transcriptase inhibitors (NNRTI) - which drugs are contraindicated in pregnancy
Delavirdine and efavirenz
HIV - integrase inhibitors - drugs? / mechanism of action
- raltegravir
- Elvitegravir
- Dolutegravir
inhibits HIV genone integration into host cell chromosome by REVERSIBLY inhibiting HIV integrase
integrase inhibitors - toxicity
increased creatine kinase
HIV - fusion inhibitors - drugs and mechanism of action
- Enfuvirtide –> Binds gp41, inhibiting viral entry
2. Maraviroc –> Binds CCR-5 on surface of T cells/monocytes, inhibiting interaction with gp120
HIV - fusion inhibitors - toxicity
skin reaction on injection sites (Enfuvirtide)
Jarisch - Herheimer reaction - epidemiology
48 hr after initiating treatment for sypilis (MC 1ry or 2ry / May also seen with treatment of other spirochete (Lyme, leptospirosis)
Jarisch - Herheimer reaction -clinical presentation
- acute onset of fever, chills, myalgias, hypotension
- rash progression in 2ry syphilis
Jarisch - Herheimer reaction - treatment
supprortive (self limited in 48 h)
2ry sypthilis - treatment / how to confirm treatment
single IM penicillin benzathine
confirm treatment by a 4-fold decrease in serologic test in 6-12 months
2ry syphilis - mouth
raised, grey, mucosal patches
epitrocheleal lymphadenopathy is pathognomonic of
2ry syphilis
treatment of syphilis if penicillin allergy
doxocycline
VDRL in primary syphilis - FN
20-30% –> if u suspcet syphilis but is (-), make a FTA ABS (sensitivity 97%)
RPR, VDRL - features
- antibody to cardiolipin-chlesterol-lecithin antingen
- quantitive
- FN in early infection
- decrease titers confrism treatment
FTA, ABS - features
- antibody to treponemal antigens
- qualitative (reactive/nonreactive)
- greater sensitivity in early infection
- (+) after treatment
indications for syphillis screening
- pregnant women at 1st preatal visit
- Anohter STD
- men sex men
- commercial sex workers
sign of succesfull syphilis treatment
4 fold decrease in antibody titers at 6-12 months
syphilis - neonatal manifestation
OFTEN RESILTS IN STILLBIRTH, HYDROPS FETALIS
- facial abnormalities
- snuffles (nasal discharge)
- saddle nose
- notched (Hutchinson) teeth
- mulberry molars
- short maxilla
- saber shins
- CN VIII deafness
congenital infection - unique for syphilis
Rhinorrhea
abd long bone radiographs
desquamating or bullous rash
indications for syphillis screening
- pregnant women at 1st preatal visit
- Anohter STD
- men sex men
- commercial sex workers
Bacillary angiomatosis - epidemiology
- Bartonella
- Ct expodure or homelessness
- severe immunodef: CD4 less than 100
bacillary angiomatosis - manifestation
- vascular cutaneous lesions (papular, nodular, peduncilar)
- systemic symptoms (fever, nodular, fatigue)
- oragn involvement rarely (liver, bone, CNS)
bacillary angiomatosis - diagnosis / treatment
lesional biopsy
treatment: doxycycline or erythromycin, antiretroviral
kaposi - how many CD4
less than 200