Opportunistic Infections in HIV

Question 1

What do we see at relatively high CD4 counts?

Answer 1

TB and thrush

Question 2

what appears as CD4 <200

Answer 2

Pneumocystis jivorecci

Question 3

what appears as CD4 < 100

Answer 3

toxoplasmosis and cryptococcus

Question 4

What appears as CD4 <50?

Answer 4

MAC and CMV infections

Question 5

Thrush: when do you see it, what do you see, dx, treatment

Answer 5

seen when CD4 is below 300, usually. caused by candida. see cheesy white exudate with erythematous mucosa below. if in doubt, scrape and examine- don’t culture. treat with nystatin swish and swallow or with oral fluconazole. culture for resistance if it doesn’t go away.

Question 6

oral hairy leukoplasia

Answer 6

overgrowth of EBV. see white lesions on the side of the tongue and the buccal mucosa

Question 7

HIV pt is having difficulty swallowing but has no candida in the mouth. what do you suspect? How do you treat?

Answer 7

aphtous ulcers. Treat with thalidamide

Question 8

Esophagits in HIV pts

Answer 8

often candida- fluconazole or nystatin. If not getting better, get endoscopy with biopsy. CMV and HSV can cause this. Tx is acyclovir or gancyclovir

Question 9

Diarrhea etiologies in HIV pts

Answer 9

salmonella (think reptiles)
C diff (even w/o abx exposure)
atypical mycobacteria (MAC) can cause chronic diarrhea
cryptosporidia (from infected food and water. is a parasite. no tx- just get own immune system to work again. cause of wasting)
CMV colitis: dx requires colonoscopy. see severe bloody diarrhea. multible ulcers with intranuclear inclusion bodies. this is seen late in infection. look for CMV in other places too if you find CMV colitis.

Question 10

Sinusitis in HIV pts

Answer 10

H flu and S pneumo, bacterial sinusitis, mucor in advanced disease (often fatal)

Question 11

S pneumo in HIV pts

Answer 11

common. often accompanied by bacteremia. this may be one of the first signs of infection. give pneumococcal vaccine to HIV positive patients, preferably with CD4 counts above 200.

Question 12

Pneumocystis pneumonia (PCP)

Answer 12

cuased by pneumocystist jivorecci. less common now because we use abx and anti-retrovirals. usually seen in pts with CD4<200. also in thos with thrus, fever, night sweats, wasting, non-productive cough.

Question 13

PCP Dx

Answer 13

normal or bilateral infiltrates (or lobar infiltrates) on CXR
increased lactate dehydrogenase and decreased O2 stats with exercise.
definitive diagnosis with visualization of the organism in sputum or bronchoalveolar lavage fluid or PCR.

Question 14

PCP treatment

Answer 14

Bactram. if severe, give abx and steroids

Question 15

TB and HIV

Answer 15

number one killer of HIV infected ppl worldwide
seen with relatively high CD4 counts.
with lower CD4 counts may see disseminated disease in bone, brain, meninges, GI, or lymph nodes. must be managed by an expert.

Question 16

MAC

Answer 16

this is atypical mycobacterium (mycobacterium avium complex). see as a complication of late disease: CD4 <50. dee disseminated disase with fever, night sweats, weight loss. people often bacteremic. Dx is with blood culture

Question 17

MAC treatment

Answer 17

macrolide WITH ART, ethambutol, rifatbutin 0?) and a quinilone?

Question 18

CNS toxoplasmosis

Answer 18

seen with CD4 < 100-200. usually a reactivation syndrome, and we try to prevent primary infection in HIV+ ppl. see fever, headache, and focal neurologic signs. may see seizures. suspect this if there are multiple lesions on the MRI and the pt is seropositive for toxoplasmosis, but you should also consider CNS lymphoma. treat empirically for 2 wks, then reimage. If they aren’t going away, consider lymphoma again.

Question 19

Crytpococcus neoformins

Answer 19

common cause of meningitis in AIDS pts with CD4 less than 100. see fever, nausea, vomiting, headache (nuchal rigidity often absent).

Question 20

cryptococcus neoformins: Dx and treatment

Answer 20

LP will have high pressure, increase protein, and roughly normal WBCs. for Dx you should be able to visualize encapsulated cryptococcal organisms. treat with amphotericin B and fluconazole maintenance, plus shunts for increased intracranial pressure

Question 21

JC virus

Answer 21

causes progressive multifocal leukoencephalopathy

see small subcortical demyelinations, prolonged neurlogic course. Dx with JC in CSF. only treatment is ART

Question 22

Primary CNS lymphoma

Answer 22

usually EBV positive. Often see focal neuro problems, seizures. May see B signs in about half of the pts who have this (fever night sweats, weight loss). you will see a single lesion in the deep white matter with less contrast enhancement than in toxo (though in reality distinguishing the two is tricky)

Question 23

CMV retinitis

Answer 23

usually seen with CD4 < 50, but start screening when CD4 ll see cheese pizza (perivascular hemorrhage and exudate). this is a necrotic, irreversible inflammatory process.  treat with gancyclovir, maybe foscaret and cidofovir.  
 aka PORN (progressive outer retinal necrosis)