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
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
3
Q
HIV Complications?
A
- Problems of the oral cavity
- GI problems
- Skin problems
- STDs
- Pulmonary problems
- Neurological problems
- Malignancies
4
Q
Oral cavity oppurtunistic infections?
A
- hairy leukoplakia
- oral (pharyngeal) candidiasis
- aphthous ulcers
- necrotizing ulcerative gingivitis
- oral herpes simplex
- KS lesions
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
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
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
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)
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
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
11
Q
Causes of dysphagia in HIV?
A
- Candidia infection of oesophagus
- Herpes simplex infection
- CMV-infection
- Malignant cause: KS or carcinoma
12
Q
Diagnosis of esophageal complications?
A
- 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)
13
Q
Common pathogens and their treatment in chronic diarrhea?
A
- Giardia, E.histolytica - metronidazol
- Cryptosporidium - HAART
- Microsporidium - HAART
- Isospora belli - CTX
- Salmonella – Ciproxin (dysenteria, fever)
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
15
Q
Skin complications and treatment?
A
- 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!!
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!
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
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
19
Q
Pulmonary complications?
A
- Bacterial pneumonias (most common: Str. Pneumoniae, but be aware of atypicals)
- TB
- PJP, viral- and other infections like fungus
20
Q
Difficulty in diagnosis of PJP?
A
- Bronchoscopy in general not available
- Diagnosis is a clinical diagnosis
- “exclusion of other causes”
21
Q
Typical investigation features of PJP?
A
- O₂ saturations - hypoxia
- CXR: Diffuse interstitial or hyperinflation; bats wing shadow
22
Q
PJP on physical exam?
A
NORMAL PHYSICAL EXAM
23
Q
Treatment of PJP?
A
- ART
- Cotrimoxazole 120 mg/kg divided into 3 doses for 3 w
- Prednisone initially 8 tabs BD 5d than tapering
24
Q
Clinical signs of TB?
A
- very variable depending on organs affected
- Persistent fever / drenching night sweats
- weight loss
- failure to thrive
- cough
- anemia
25
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
26
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%
27
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
28
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
29
Neurological complications?
1. cryptococcal meningitis
2. cerebral toxoplasmosis
30
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
31
Management of cryptococcal meningitis?
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
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
33
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
34
Malignancies?
1. KS lesions
2. lymphoma
35
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)
36
Treatment of KS lesions?
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
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
38
Role of viral infections in malignancies?
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
What is TB preventative therapy?
TPT: can prevent active TB disease in people who are at high risk.
3HP + pyridoxine (alternative 6H + pyridoxine)
40
Who gets TBT?
HIV infected children and adults in all districts of Malawi
41
Who is not eligible for TBT?
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
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.
43
Contraindications for TBT?
active TB
44
What is cotrimoxazole preventive therapy (CPT)?
CPT 960 mg OD
- CPT prevents PCP pneumonia, diarrhea, malaria and other HIV-related diseases and prolongs survival.
45
Who can get CPT treatment?
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
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
47
When to do urine LAM and serum CrAg?
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
Results of urine LAM?
pos: treat for TB
neg: does not rule out TB. Continue with TB investigations
49
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
50
Screening?
VIA screening to prevent cervix carcinoma every 12 m
Fasting blood, if 40+ every 12 m
Blood pressure if 30+ every 12m
