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MBBS 4: Family Medicine > Oppurtunistic Infections > Flashcards

Oppurtunistic Infections Flashcards

1
Q

What is an opportunistic infection?

A

A microorganism that is usually harmless but can become pathogenic when the host’s resistance to disease is impaired.
- It can be any microorganism: virus, parasite, fungus or bacteria

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2
Q

WHO Clinical HIV staging?

A

HIV-related diseases are grouped into 4 WHO clinical stages that correlate with disease progression and prognosis of survival:
Stage 1: Asymptomatic
Stage 2: Mild
Stage 3: Advanced
Stage 4: Severe

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3
Q

HIV Complications?

A
  1. Problems of the oral cavity
  2. GI problems
  3. Skin problems
  4. STDs
  5. Pulmonary problems
  6. Neurological problems
  7. Malignancies
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4
Q

Oral cavity oppurtunistic infections?

A
  1. hairy leukoplakia
  2. oral (pharyngeal) candidiasis
  3. aphthous ulcers
  4. necrotizing ulcerative gingivitis
  5. oral herpes simplex
  6. KS lesions
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5
Q

Oral hairy leukoplakia?

A
  • Typical on the side of the tong, hairy appearance
  • Ebstein Bar Virus (EBV) related
  • Permanent, you can’t remove the patches with a toothbrush
  • Not painful
  • Malignant transformation rates of oral leukoplakia range from 0.13 to 17.5%
  • Treatment: HIV suppression with ARVs
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6
Q

Oral pharyngeal candidiasis?

A
  • Infection with the fungus Candida albicans accumulating in the mouth
  • Multiple white or reddish patches in mouth
  • Painful, burning of nature
    Can be (partly) scraped off the tong
  • Difficulty swallowing (suggests pharyngeal spread)
  • Management : nystatin, fluconazole
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7
Q

Apthous ulcers?

A
  • Painful ulcers
  • Can be anywhere in the mouth
  • Can even cause 2nd nutritional problems due to pain
  • Management: topical lignocaine, HIV suppresion with ARVs
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8
Q

Necrotizing ulcerative gingivitis?

A
  • Sudden onset of inflammation, pain, and the presence of “punched-out” crater-like lesions of the papillary gums
  • Gums bleed easily
  • Management: antibiotics in severe cases (clindamycin, augmentin)
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9
Q

Oral herpes simplex?

A
  • HSV infections are common in people who have HIV
  • Mostly recurrent
  • Cause painful sores.
  • HSV-1 typically causes sores on or near the mouth
  • Management: Acyclovir and ARV
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10
Q

KS lesions?

A
  • Cancer that causes patches of abnormal tissue to grow on the palate
  • Be aware of other places!
  • These patches, or lesions, are usually red or purple.
  • Management: HIV suppression with ARV, chemotherapy
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11
Q

Causes of dysphagia in HIV?

A
  1. Candidia infection of oesophagus
  2. Herpes simplex infection
  3. CMV-infection
  4. Malignant cause: KS or carcinoma
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12
Q

Diagnosis of esophageal complications?

A
  1. Abnormality in oral cavity present: same abnormality can be present in esophagus
  2. Oral cavity normal: if available: endoscopy, if endoscopy not possible consider treatment for candida esophagitis
    – Fluconazole 200mg od/14 days (particularly with CD4<200)
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13
Q

Common pathogens and their treatment in chronic diarrhea?

A
  1. Giardia, E.histolytica - metronidazol
  2. Cryptosporidium - HAART
  3. Microsporidium - HAART
  4. Isospora belli - CTX
  5. Salmonella – Ciproxin (dysenteria, fever)
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14
Q

Treatment of chronic diarrhea?

A

Confirm VL suppression, do targeted CD4
Based on response to stepwise empirical treatment:
1. Treat isospora, cyclospora, bacterial Cotrimoxazol 960mg BD 7/7
2. Treat giardia, clostridium, amoeba, microsporidium Metronidazol 750mg TDS 7/7
3. Treat microsporidium, helminths Albendazol 400 mg BD 6/12

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15
Q

Skin complications and treatment?

A
  1. Seborrheic eczema: miconazole/ketoconazole creme/lotion
  2. Pruritic rash: complication of HIV-infection in untreated patient or complication of ARV
  3. Herpes simplex: in HIV HSV can be recurrent
  4. H. zoster: can be multidermal and more severe, treatment: acyclovir/valaciclovir, treatment for neuralgia
    - General treatment: HIV suppression with ARVs!!
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16
Q

STD complications?

A

More chronic, more severe
1. Herpes simplex and genital warts: often chronic
2. Gonorrhoea, chlamydia: certain subtypes can cause lymphogranuloma venerum - with inguinal nodes and need for prolonged treatment)
3. Syphilis: with HIV more often neurosyphilis!

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17
Q

Genital warts?

A
  • Caused by human papillomavirus (HPV) creating small, painless bumps in the genital region
  • Untreated, may develop a fleshy, cauliflower-like appearance.
  • Genital warts may cause cervical cancers and other genital cancers.
  • Management: Can be treated topically(applied to skin), freezing, or surgical removal
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18
Q

HPV vaccination?

A
  • After 5 year sexual intercourse 98% seropositivity for HPV- 16/18 antibodies, so: vaccination should start around age of 12
  • Already implemented in many industrialized countries (at the age of 12 years )
  • Decrease of incidence of cervix carcinoma can be realized
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19
Q

Pulmonary complications?

A
  1. Bacterial pneumonias (most common: Str. Pneumoniae, but be aware of atypicals)
  2. TB
  3. PJP, viral- and other infections like fungus
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20
Q

Difficulty in diagnosis of PJP?

A
  1. Bronchoscopy in general not available
  2. Diagnosis is a clinical diagnosis
  3. “exclusion of other causes”
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21
Q

Typical investigation features of PJP?

A
  1. O₂ saturations - hypoxia
  2. CXR: Diffuse interstitial or hyperinflation; bats wing shadow
22
Q

PJP on physical exam?

A

NORMAL PHYSICAL EXAM

23
Q

Treatment of PJP?

A
  1. ART
  2. Cotrimoxazole 120 mg/kg divided into 3 doses for 3 w
  3. Prednisone initially 8 tabs BD 5d than tapering
24
Q

Clinical signs of TB?

A
  1. very variable depending on organs affected
  2. Persistent fever / drenching night sweats
  3. weight loss
  4. failure to thrive
  5. cough
  6. anemia
25
Q

Diagnosing TB in HIV+ patients?

A

Diagnosis often difficult to confirm in HIV+ patients.
1. Urine LAM: For all ‘ill’ patients, inpatients, CD4<200
2. 2x sputum for Xpert
- Also consider for Xpert: ascites, CSF, lymph gland material, pleural or pericardial fluid
3. CXR: fine needle aspiration nodes (for microscopy)
4. pleural tap for biochemistry: straw coloured effusion?
5. Lumbar puncture: CSF for biochemistry, microscopy

26
Q

TB xray?

A

Often atypical radiological picture:
1. Hilar/mediastinal adenopathy 20-50%
2. Pleural effusion 12-28%
3. Miliairy TB 7-18%
4. Normal x-chest, pos. sputum12%

27
Q

TB treatment?

A

2 RHZE, 4 RH
- Note that DGT (and RAL) needs to be doubled while using rifampicin
- Continue this 7 days after stop of TB treatment

28
Q

Bacterial pneumonia?

A
  • Often more severe in HIV+ patient.
  • When severe presentation:
    Start Ceftriaxone 2g IV + macrolide or doxycycline
    Add Gentamycin if no response
  • this is done to cover atypical and gram negative bacteria
29
Q

Neurological complications?

A
  1. cryptococcal meningitis
  2. cerebral toxoplasmosis
30
Q

Cryptococcal meningitis?

A
  • Consider the diagnosis in every HIV seropositive patient with chronic and severe headache, even without fever
  • DD: TB meningitis, toxoplasmosis, bacterial meningitis
  • Diagnosis: LP, crAg, serum crAg
31
Q

Management of cryptococcal meningitis?

A
  1. Liposomal amphotericin B 10 mg/kg/day
    AND flucytosine 100mg/day 2wks, AND fluconazole 1200mg/day 2 wks, then 800mg 8w than 200 mg lifelong (Pre-hydrate 1000 ml, K+, MgSO before ampho B infusion)
    - Only start ART 5 w after treating the cryptococcal meningitis
  2. fluconazole from the beginning
32
Q

Cerebral toxoplasmosis?

A
  • Clinical signs: New convulsions, possibly reduced consciousness, focal neurological symptoms
  • Only seen in patients with CD4 below 200 cells/ml
  • Most frequent cause of cerebral mass lesion with (focal) neurological deficits
  • CT scan in general unavailable
  • Practical advise: in febrile HIV-infected patients with unexplained cerebral symptoms/neurological deficits start treatment for cerebral toxoplasmosis after exclusion of malaria and meningitis
33
Q

Mangement of cerebral toxoplasmosis?

A

Cotrimoxazole tablets 960 mg 2 tabs 12-hourly for 6 weeks then 1 tabs 12-hourly for 3 months then 1 tab 24 hourly as lifelong prophylaxis
- Response to this treatment in 7-10 days makes toxoplasmosis very likely

34
Q

Malignancies?

A
  1. KS lesions
  2. lymphoma
35
Q

Kaposi sarcoma?

A
  • Single or multiple purple patches or nodes, mainly mouth, skin, conjunctiva, lung, GI tract
  • Children: often no skin lesions, only oedema and non-localized adenopathy.
  • Diagnosis Usually clear picture; consider KS even without skin or oral lesions if no response to EPTB therapy within 4 weeks (adults)
36
Q

Treatment of KS lesions?

A
  1. ART, analgesia
  2. Start chemotherapy only if no improvement after 3 months on ART.
    - Immediate chemotherapy in case of KS stage T1; Any pediatric KS and KS in mouth/ internal organs/ nodular skin KS, skin KS with oedema
  3. Chemotherapy 1st choice: paclitaxel IV
  4. Chemotherapy 2nd choice: bleomycin + vincristine
37
Q

Lymphoma?

A
  • Clinical Signs: Swollen lymph nodes, loss of weight, low-grade fever, night sweats, anaemia
  • 200-600 times more common in HIV patients
  • Most are B-cell lymphomas
  • Diagnosis: lymph node biopsy
  • Treatment: refer to oncology for possible chemotherapy
38
Q

Role of viral infections in malignancies?

A
  1. Human Herpes Virus (HHV-8): KS
  2. Epstein Bar (EBV): malignant lymphoma
  3. Human Pappiloma Virus (HPV): cervix carcinoma
  4. Hepatitis B (HBV): hepatocellular carcinoma (HCC)
  5. Hepatitis C (HCV): hepatocellular carcinoma (HCC)
39
Q

What is TB preventative therapy?

A

TPT: can prevent active TB disease in people who are at high risk.
3HP + pyridoxine (alternative 6H + pyridoxine)

40
Q

Who gets TBT?

A

HIV infected children and adults in all districts of Malawi

41
Q

Who is not eligible for TBT?

A
  1. Children on paediatric doses of ART should not use 3HP
  2. Women on family planning
    - Rifapentine reduces contraceptive effectiveness
  3. Rifapentine reduces effectiveness of Malaria treatment
  4. Pregnancy and the first 3 m postpartum due to increased risk of liver failure
42
Q

For children staying with a patient with pulmonary TB?

A

Children under 5 years – regardless of HIV status - who live with a patient with pulmonary TB (sputum smear negative or positive; in all districts). Give 6 months course of 6H.

43
Q

Contraindications for TBT?

A

active TB

44
Q

What is cotrimoxazole preventive therapy (CPT)?

A

CPT 960 mg OD
- CPT prevents PCP pneumonia, diarrhea, malaria and other HIV-related diseases and prolongs survival.

45
Q

Who can get CPT treatment?

A
  1. HIV exposed children from age 6 weeks until confirmed neg at 2 year
  2. HIV infected children from age 6 weeks
  3. EVERY HIV infected adults, lifelong
    Note: Contraindication - Jaundice
46
Q

Describe routine urine LAM and Serum CrAg?

A

Routinely test all children 5 years+ and adults with signs for advanced HIV:
- Urine LAM for disseminated TB
- CrAG for cryptococcal meningitis (CM) / subclinical cryptococcaemia

47
Q

When to do urine LAM and serum CrAg?

A
  1. CD4 < 200
  2. WHO stage 3 or 4 before ART initiation
  3. “Seriously ill” HIV+ pt
    - Adult: RR >30/min, pulse >120/min, unable to walk, T >39
    - Child: lethargy, convulsions, loss of consciousness, unable to feed, repeated vomiting, T >39, tachycardia, tachypnea
  4. All admitted HIV+ pt
48
Q

Results of urine LAM?

A

pos: treat for TB
neg: does not rule out TB. Continue with TB investigations

49
Q

Results of serum CrAg?

A

pos: assess for active meningitis signs, treat for active meningitis or give pre-emptive antifungal therapy
neg: does not rule out CM. Continue with CSF testing (CrAg, Indian ink, Xpert) and other investigations for patient with meningitis signs

50
Q

Screening?

A

VIA screening to prevent cervix carcinoma every 12 m
Fasting blood, if 40+ every 12 m
Blood pressure if 30+ every 12m

MBBS 4: Family Medicine (27 decks)

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