HIV - virus and clinical lecture Flashcards
Best test to diagnose for HIV?
HIV RNA PCR (can also detect prior to seroconversion), also used to follow response to ART
Current recommendation is to do a combined antibody/antigen assay, that detects p24 antigen + HIV antibodies (this will also detect an acute infection)
Acute/Primary HIV infection:
When is the onset after exposure?
What are the symptoms?
Onset 1-4 weeks after exposure
50-90% of people have at least some symptoms but htey are nonspecific- mimics EBV, CMV, syphilis, measles and other viral illnesses
Ie) fever, fatigue, pharyngitis, wt losos, myalgias, lymphadenopathy, thrombocytopenia, leukopenia, maculopapular rash, oral ulcers, H/A, diarrhea, N/V, aspectic meningitis
How do we characterize an acute/primary infection?
What is the significance?
High viral loads
below normal CD4 count (NL: 500-1200)
High risk of transmission –>need to recognize and dx to tyr to reduce secondary transmission
Who should we screen?
everyone 13-64 y/o as part of routine health care (req. to opt out rather than opt in)
People at high risk? ANNUALLY
Test those with STI, TB, illness compatible with HIV, pregnant
How do we know if treatment is effective?
Run a RNA PCR at baseline and periodically through treatment
viral load should become undetectable if effective ART
20-50 copies/mL
What is the baseline evalv of HIV?
Then what…
Complete history and exam
Screen for depression, immunization status, travel hx…
ROS directed at possible opportunistic complications
Labs…tons of them.
STIs, infections, pap smear, Toxo, labs for med side effects and genotypes (ie -HLA B5701)
THEN:
Monitor HIV via: CD4 counts, viral load every 3-6 months, more often if changing/starting ART
Regular chemistries, CBC to monitor side effects
When do we start ART?
What are the goals of ART? (4)
Right away. Treat all persons with HIV regardless of CD4
Goals:
- Improve survival
- Improve QOL
- Restore immune funciton
- DEC HIV transmission
What is still lacking in HIV treatment?
What are HIV positive individuals at higher risk for?
Doesn’t fully restore health - gap in lifespan
ONLY 30% are virally suppressed, only 40% engage in care! – lacking HIV care treatment to those who need it
INC risk of non-HIV complications: CVD, non-AIDS cancers, osteoporosis, renal dz, neurocognitive decline
HIV and its treatment may be risks for accelerated aging and organ damage, side effects of ART (DM, lipid/renal/CV disorders)
What are HIV+ individuals at risk during….
Primary HIV (5)
CD > 50 (3)
CD 200-500 (4)
CD <200 (8)
What are HIV+ ppl always at increased risk for?
Primary HIV: fever, pharyngitis, myalgias, adenopathy, rash
CD > 50: neuropathy, bell’s palsy, thrombocytopenia
CD 200-500: Shingles, TB, bac pneumo, non-CNS lympoma
CD <200: Trush, PJP, Kaposi Sarcoma, Cyptococcus, MAC, CMV, PML, CNS lymphoma
What are HIV+ ppl always at increased risk for? Bell’s palsy
Greater immuno suppression
What are some initial HIV manifestations that could point us to HIV?
Seborrheic dermatitis - superficial fungal infection at nasal/labio folds
Hairy Leukoplakia (EBV) - doesn’t respond to therapy
Herpes Zoster (worry about eye with nasal invovlement
What is the presentaiton of Pneumocystitis Pneumonia?
What are usually the CD4 counts we see this at?
What are some lab findings and symptoms?
Dx
Tx
Prophylaxis??
Often insidious symptoms presents for weeks
Exam is normal, but pt can desaturate quickly with walking
ELEVATED LDH (nonspecific)
CXR - can be nl in 10-39% of the pt with PJP OR
bilateral reticulonodular interstitial infiltrates, perihilar CT more sensitive
RISK FACTORS: CD4 <200, oropharyngeal candidiasis or AIDS-defining illness
DX: sputum or BAL DFA/PCR or cytology
TX: TMP-SMX, clinda/primaquine, prednisone if significant hypoxia
Keep on TMP-SMX until CD >200 for more than 3 months
Alt: dapsone (if G6PD is normal) atovaquone, inhaled pentamidine
What are other common lung disease of HIV? (8)
Bac pneumo (S. pneumo)
TB
histoplasmosis
blastomycosis
coccidioidomcosis (SW US)
crytococcus
Respiratory viruses (influenza)
tumors- lymphoma, Kaposi’s sarcoma
DX: sputum/BAL, or biopsy
Toxoplasmosis
What is it associated with?
When would we see it more often (CD4 counts?)
What would be typical manifestations of toxo?
How should a possible toxo case be managed?
Associated with undercooked meat with tissue cysts or ingesting cysts tha have been shed in cat feces
CD4 <100, esp <50
Typical manifestations: encephalitis with multiple brain lesions often ring-enhancing @ basal ganglia!
other symptoms may be non specific
Obtain baseline IgG
Positive? empiric Tx and assess response
If safe? LP with T. gondii PCR
If negative or lack of response to empiric tx - brain biopsy
Treatment and prevention options for Toxo?
Sulfadiazine + pyrimethamine
Clindamycin + pyrimethamine
TMP-SMX (bactrim)
PREVENTION:
Bactrim daily until CD >200, for more than 3 months
Avoid raw/uncooked meath, shellfish
Avoid changing litter box, keep cats indoors, no raw meat
(same for pneumocystis)
What are some brain lesions that could be seen in HIV and their associated ilness (3):
toxo - ring enhancing
JC virus - progressive multifocal leukoencephalopathy (PML)
deep white matter lesions, no edema, no contrast enhancement, progressive cognitive, focal neurologic deficits, no brain sx like h/a
HIV encehalitis - large ventricles
lots of atropy, cognitive, behavior decline, dementia
