Lecture 27: Opportunistic Infections Flashcards
What is the main cause for Opportunistic Infections?
- Decrease of CD4 cells = decrease in cell-mediated immunity
At what CD4 Cell Count is the highest risk of starting to develop Opportunitic Infections?
- < 500 cells/mm3 [expecially < 200]
What are some of the Opportunistic Infections that could occur at 200-500 CD4 cell count?
- TB [Cough up blood, night sweats, weight loss]
What are some of the Opportunistic Infections that could occur at < 200 CD4 cell count?
- Pneumocystis Jiroveci (PJP) [increased LDH, Hypoxia]
- Crytosporidium [watery diarrhea]
- Candida [Thrush, Oral Lesion]
- Fungal Pneumonia
What are some of the Opportunistic Infections that could occur at < 100 CD4 cell count?
- Toxoplasmosis [Ring Lesions on Brain]
- Candidal, HSV or CMV esophagitis
What are some of the Opportunistic Infections that could occur at < 50 CD4 cell count?
- CMV [Visual changes, esophagitis, entertitis…]
- Cyptococcus [headache, altered mental, +india ink]
- MAC [Night sweats, weight loss, diarrhea, malaise]
- CNS Lymphoma
What is the difference between Primary & Secondary prohylaxis?
- Primary: Agents to prevetn first episode based on CD4 levels
- Secondary: Agents to prevent further recurrences of OIs
What does IRIS mean and what are some of the OIs that can induce IRIS?
- IRIS: Immune Reconstitution Inflammatory Syndrome = high fevers, malaise, worse clinical outcomes of OI
- Seen in: MAC, TB, PJP, Toxo, Hep B & C, CMV, Crypto, Histo, ZVZ
Typically begins wihtin 4 - 8 weeks of starting ARTs
Treat with NSAIDS or Cortiosteriods
What are the most common infections due to Candida Species?
- Oropharyngeal Candidiasis [Thrush]
- Esophegeal Candidiasis
mostly caused by C. Albicans
OPC = < 200 & EC is normall seen lower than that
What is the Clinical Manifestations and Management for Oropharyngeal Candidiasis?
“Thrush”
- Painless, Creamy white, plaques on the cheek, roof of mouth or tounge
- Topically: Nystatin or Clotrimazole [NOT for HIV]
- Systemic: Fluconazole 100 mg PO QD for 7 - 14d –> Preferred (superior to topical)
What is the Clinical Manifestations and Management for Esophageal Candidiasis?
- Fever, Retrosternal Burning, swallowing pain and difficulty
- Systemic: Fluconazole 200 mg IV or PO QD for 14 - 21 days –> Topical NOT effective
What is the Clinical Manifestations and Management for Vulvovaginal Candidiasis?
- Thick, adherent white vaginal discharge, itching, burning, redness
- Treatment: Topical Azoles; Oral fluconazole; Itraconazole Solution [Severe = PO Fluconazole >7days] (C. Glabrata = Boric Acid Vaginal Suppository)
When should Prophylaxis be used for any Candidiasis OIs?
- NOT recommended –> only superficial and Not life threatening
What is the Clinical Manifestations and Management for Cryptocccal Meningitis?
3 Phase Managmetn –> Induction, Consolidation, maintenance
- Can have fever, malaise, headache, neck stiffness [subacute (chronic) meningitis]
- Treatment: induction: L AMP B + 5-FC ~12w then consolidation: fluconazole 800 gm PO QD for ~8w then maintenacne: fluconazole 200 PO QD for 1y
What is some of the diagnosis for Cryptococcus Meningitis?
- CSF analysis = normalish glucose, few WBCs, Elevated Cryptococcal antigen
- Patients also have + Serum Cryptococcal Antigen Titer
What is the Primary Prophylaxis for Cryptococcal Meningitits?
- NOT Rcommended
What is the Secondary Prophylaxis for Cryptococcal Meningitis?
- Chronic or Suppressive Therapy with PO Fluconazole for 1 year
- Can D/C if Asymptomatic and CD4 > 100
35 - 65% patient with AIDS will relapse
What are some important things to note about Pneumocystis Jirovecii Pneumonia (PJP)?
Pathogensis?
- PJP is allover our bodies but the the skin help protect
- Most of the cases (90%) develop in HIV patients with a CD4 count < 200 or 14%
What is the Clinical Manifestations of Pneumocysits Jirovecii Pneumonia?
- SOB, Fever, Non-productive cough, and chest discomfort that takes days to weeks to delevop
- Exam: Tachycardiam Tachypenia, SOB
CAP has the same signs but its sudden onset
What is the diagnosis of PJP?
- Arterial Blood gas: Hypoxemia (pO2 < 70)
- CXR: Diffuse, bilateral, symmetrical, “ground glass”
- High 1,3 b-D-glucan [part of the cell wall]
What is the treatment for PJP?
- TMP-SMX 15-20mg/kg/day of TMP IV/PO q6-8h for 21 days
- Adjuctive Corticosteriods for MOD-SERVERE [When PaO2 < 70; start prednisone 40mg BID x5d; 40 mg QD x5d; 20 mg QD x11d]
Pred should be started at the same time as Bactrim
Untreated = fatal
What the is Primary Prophylaxis for PJP?
When to start? Drugs? D/C?
- Helps prevent First episode fo PJP in ALL HIV patients [CD4 < 200; 14%]
- Bactrim DS PO QD or SS PO QD
- D/C when CD4 count is 100-200 for 3m
Bactrim DS good for Toxo [CD4 < 100]
What is the Secondary Prophylaxis for PJP?
When to start? Drugs? D/C?
- Given after completion of treatmetn for ALL
- Bactrim DS PO QD or SS PO QD
- D/C when CD4 count is > 200 for 3m
Bactrim DS good for Toxo [CD4 < 100]
What are some of the alternactive prophylaxis for PJP
- Bactrim DS three times weekly
- Dapsone 100mg PO QD
- Atovaquone 1500mg PO QD (with food)
- Pentamidine 300mg/month
Dapsone NOT good for Toxo
