Oppurtunistic Infections Flashcards
What is an opportunistic infection?
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
WHO Clinical HIV staging?
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
HIV Complications?
- Problems of the oral cavity
- GI problems
- Skin problems
- STDs
- Pulmonary problems
- Neurological problems
- Malignancies
Oral cavity oppurtunistic infections?
- hairy leukoplakia
- oral (pharyngeal) candidiasis
- aphthous ulcers
- necrotizing ulcerative gingivitis
- oral herpes simplex
- KS lesions
Oral hairy leukoplakia?
- 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
Oral pharyngeal candidiasis?
- 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
Apthous ulcers?
- Painful ulcers
- Can be anywhere in the mouth
- Can even cause 2nd nutritional problems due to pain
- Management: topical lignocaine, HIV suppresion with ARVs
Necrotizing ulcerative gingivitis?
- 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)
Oral herpes simplex?
- 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
KS lesions?
- 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
Causes of dysphagia in HIV?
- Candidia infection of oesophagus
- Herpes simplex infection
- CMV-infection
- Malignant cause: KS or carcinoma
Diagnosis of esophageal complications?
- Abnormality in oral cavity present: same abnormality can be present in esophagus
- Oral cavity normal: if available: endoscopy, if endoscopy not possible consider treatment for candida esophagitis
– Fluconazole 200mg od/14 days (particularly with CD4<200)
Common pathogens and their treatment in chronic diarrhea?
- Giardia, E.histolytica - metronidazol
- Cryptosporidium - HAART
- Microsporidium - HAART
- Isospora belli - CTX
- Salmonella – Ciproxin (dysenteria, fever)
Treatment of chronic diarrhea?
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
Skin complications and treatment?
- Seborrheic eczema: miconazole/ketoconazole creme/lotion
- Pruritic rash: complication of HIV-infection in untreated patient or complication of ARV
- Herpes simplex: in HIV HSV can be recurrent
- H. zoster: can be multidermal and more severe, treatment: acyclovir/valaciclovir, treatment for neuralgia
- General treatment: HIV suppression with ARVs!!
STD complications?
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!
Genital warts?
- 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
HPV vaccination?
- 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
Pulmonary complications?
- Bacterial pneumonias (most common: Str. Pneumoniae, but be aware of atypicals)
- TB
- PJP, viral- and other infections like fungus
Difficulty in diagnosis of PJP?
- Bronchoscopy in general not available
- Diagnosis is a clinical diagnosis
- “exclusion of other causes”
Typical investigation features of PJP?
- O₂ saturations - hypoxia
- CXR: Diffuse interstitial or hyperinflation; bats wing shadow
PJP on physical exam?
NORMAL PHYSICAL EXAM
Treatment of PJP?
- ART
- Cotrimoxazole 120 mg/kg divided into 3 doses for 3 w
- Prednisone initially 8 tabs BD 5d than tapering
Clinical signs of TB?
- very variable depending on organs affected
- Persistent fever / drenching night sweats
- weight loss
- failure to thrive
- cough
- anemia
Diagnosing TB in HIV+ patients?
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
TB xray?
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%
TB treatment?
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
Bacterial pneumonia?
- 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
Neurological complications?
- cryptococcal meningitis
- cerebral toxoplasmosis
Cryptococcal meningitis?
- 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
Management of cryptococcal meningitis?
- 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 - fluconazole from the beginning
Cerebral toxoplasmosis?
- 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
Mangement of cerebral toxoplasmosis?
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
Malignancies?
- KS lesions
- lymphoma
Kaposi sarcoma?
- 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)
Treatment of KS lesions?
- ART, analgesia
- 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 - Chemotherapy 1st choice: paclitaxel IV
- Chemotherapy 2nd choice: bleomycin + vincristine
Lymphoma?
- 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
Role of viral infections in malignancies?
- Human Herpes Virus (HHV-8): KS
- Epstein Bar (EBV): malignant lymphoma
- Human Pappiloma Virus (HPV): cervix carcinoma
- Hepatitis B (HBV): hepatocellular carcinoma (HCC)
- Hepatitis C (HCV): hepatocellular carcinoma (HCC)
What is TB preventative therapy?
TPT: can prevent active TB disease in people who are at high risk.
3HP + pyridoxine (alternative 6H + pyridoxine)
Who gets TBT?
HIV infected children and adults in all districts of Malawi
Who is not eligible for TBT?
- Children on paediatric doses of ART should not use 3HP
- Women on family planning
- Rifapentine reduces contraceptive effectiveness - Rifapentine reduces effectiveness of Malaria treatment
- Pregnancy and the first 3 m postpartum due to increased risk of liver failure
For children staying with a patient with pulmonary TB?
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.
Contraindications for TBT?
active TB
What is cotrimoxazole preventive therapy (CPT)?
CPT 960 mg OD
- CPT prevents PCP pneumonia, diarrhea, malaria and other HIV-related diseases and prolongs survival.
Who can get CPT treatment?
- HIV exposed children from age 6 weeks until confirmed neg at 2 year
- HIV infected children from age 6 weeks
- EVERY HIV infected adults, lifelong
Note: Contraindication - Jaundice
Describe routine urine LAM and Serum CrAg?
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
When to do urine LAM and serum CrAg?
- CD4 < 200
- WHO stage 3 or 4 before ART initiation
- “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 - All admitted HIV+ pt
Results of urine LAM?
pos: treat for TB
neg: does not rule out TB. Continue with TB investigations
Results of serum CrAg?
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
Screening?
VIA screening to prevent cervix carcinoma every 12 m
Fasting blood, if 40+ every 12 m
Blood pressure if 30+ every 12m
