opportunistic infection: prevention and management Flashcards
Initiation of ART is effective treatment for OIs for which effective therapy does not exist
yep
Starting ART in the setting of acute OIs is complicated by toxicity, drug-drug interactions and IRIS
yep yep
A group of clinical syndromes associated with immune reconstitution observed most commonly for mycobacterial infections (TB, MAC), as well as with PJP, Toxo, CMV, cryptococcal infection
IRIS: Immune Reconstitution Inflammatory Syndrome
IRIS usually presents within ________ after starting ART, in patients with high viral loads and low CD4+ counts. Inflammation takes weeks to months to subside
Early initiation of _____near the time of initiating OI treatment should be considered for most patients
IRIS usually presents within first 4–8 weeks after starting ART, in patients with high viral loads and low CD4+ counts. Inflammation takes weeks to months to subside
Early initiation of ART near the time of initiating OI treatment should be considered for most patients
Indicator of immune suppression; most often seen with declining CD4 counts
candida albicans
Before widespread use of ART and prophylaxis, 80% of patients developed____
PJP
PJP
Progressive dyspnea on exertion, non-productive cough, developing over days to weeks
in PJP we see something elevated… what is it?
Elevated 1,3ß-D-glucan level
***Beta D glucan is part of cell wall of PJP cysts
Classic appearance on CXR: bilateral hilar interstitial infiltrates “butterfly pattern,” but many will have a clear CXR and can show pathchy ground glass opacities
PJP
PJP diagnosis
Induced sputum is method of choice
but BAL or transbronchial biopsy: high diagnostic yield but more invasive
PJP treatment
all treatment for 21 days
Bactrim(PO) and polus prednisone if a-a gradient >35/ acutely ill
Many patients with PJP will get worse before they get better
yep, Radiologic appearance lags behind clinical deterioration or improvement
Prophylaxis can be stopped if CD4 consistently >_____and plasma viral loads are undetectable in response to HAART
100-200
PJP prophylaxis if
CD4 <200, thrush or AIDS defining illness
Cryptococcal Meningitis caused by a
fungal organism
what do we use to identify cryptococcal meningitis in CSF
india ink
Gold standard treatment for cryptococcal meningitis
IV antifungal
with cryptococcal meningitis treatment ____ will have IRIS; manage symptoms with steroids if needed
30%- Optimal time to start ART is not clear
Mycobacterium Avium Intracellulare Complexc is a ______ growing mycobacterium. Acquired by _________; no person to person transmission. Infection with MAC is due to recent acquisition rather than reactivation; no latent phase
Mycobacterium Avium Intracellulare Complexc is a slow growing mycobacterium. Acquired by inhalation or ingestion; no person to person transmission. Infection with MAC is due to recent acquisition rather than reactivation; no latent phase
MAC lab findings
anemia, elevated Alk. Phos and elevated LDH
With MAC infection, IRIS typically presents as (2)
Can be self-limiting or can be severe and unremitting, requiring NSAIDS or steroids
With MAC infection, IRIS typically presents as lymphadenitis, granulomatous hepatitis
Can be self-limiting or can be severe and unremitting, requiring NSAIDS or steroids
MAC diagnosis
lymph node biopsy
treatment for MAC
macrolides
**All treatment should continue for at least one year
MAC prophylaxis
CD4 <50; stopped when CD4 >100
patients with CD4 counts <100 who are Toxoplasma IgG positive have a 30% probability of _______________________
developing reactivated toxo, if not on effective prophylaxis
T. gondii most commonly reactivates in ____ leading to cerebral abscess
CNS
diagnosis of toxo.
Toxoplasma seropositive (IgG positive)
Gold standard is brain biopsy
treatment of toxo.
Combination treatment (sulfadiazine and pyrimethamine/leucovorin; other options as well) for 6-8 wks, followed by suppression
CMV Most commonly causes reactivation disease in HIV+ patients with CD4
CMV Most commonly causes reactivation disease in HIV+ patients with CD4 <50. Can involve almost every organ system, but 80% of infections are manifested as retinitis in HIV+ patients
CMV with retinitis treatment (2)
- intraocular antiviral injection
2. ganciclovir
CMV in the Gi tract Usually presents with _____. Can involve any part of the GI tract from the mouth to the anus. Often more persistent and focal than candidal esophagitis
CMV in the Gi tract Usually presents with fever. Can involve any part of the GI tract from the mouth to the anus.often more persistent and focal than candidal esophagitis
treatment given when acute infection is under control but when CD4 count is still depressed
2° prophylaxis –
treatment given prior to any signs of infection when CD4 < a particular value
1° prophylaxis –
