Questions from S 20 Flashcards
Patient with perianal rash, HIV pos, suspected Mpox
What is treatment?
CD4<400 - considered high risk
Admit to neg pressure side room
FFP3/ mask/ gloves/ gown
Tecovirimat 600mg BD for 14 days PO or IV
Cidofovir 5mg/kg once a week IV
Brincidofovir
Surgical debridement - consider colostomy if significant anal lesions
Antibiotics for any bacterial infection
Re-commence and optomise ARVs
Why is brincidofovir not used in Mpox?
Not available in UK
High cost
Mpox patient with HIV failing on tecovirimat treatment
Why is this?
What action to take?
Tecovirimat has low genetic barrier to resistance
Send swab for resistance testing
switch to cidofovir
Also failing because HIV is
Mpox patient with significant perianal lesions that keep getting infected
What is management?
Surgical debridement
Consider a colostomy until lesions heal
Antibiotics for secondary bacterial infections
High risk patient with HIV wants to prevent Mpox infection
How can this be done?
Reduce exposure risk
MVA-BN - vaccine x 2 doses 1 month apart
If CD4 <200 likely to have poorer response to vaccine. May need to repeat the course when patient CD4 rises
If CD4 count does not recover, consider annual immunisation
What is Mpox case definition probable case?
New vesicular rash, particularly in perianal/ genital region
Plus
- GBMSM
- new sexual partner in past 21 days
- epidemiological link to another case in past 21 days
Neonate with raised ALT
EDTA blood sample available
What tests to send?
HSV 1/2
VZV
Adeno
Entero
Parecho
Adult patient with acutely raised ALT
What tests should be done at ESL?
HBsAg + neutralisation
Anti-HBc + IgM
Anti-HCV
HAV IgM
HEV IgM
EBV VCA IgM
CMV IgM
HIV - when to start ARVs?
Start immediately
Only delay if significant other infection, and concerns of IRIS - e.g TB
Can wait 8-12 weeks to start ARVs.
But if CD4 <50, should start immediately
New diagnosis of HIV1
What drugs to start?
2x NRTI + INSTI
Tenofovir Disoproxil fumarate 245mg
Emtrictabine 200mg
Raltegravir 1200mg
All oral, OD
Which drug classes are contraindicated in HIV2 infection?
NNRTI - Reverse transcriptase has intrinsic resistance
Fusion inhibitor - enfuvirtide - one mutation can make resistant
Entry inhibitor - maraviroc - lack of studies in this use
What is significance of HIV M184V mutation
Confers resistance to
Abacavir
Emtrictabine
Lamivudine
Increases susceptibility to zidovudine and tenofovir
Where is M184V gene located?
On Pol gene of HIV - codes for reverse transcriptase
Which CMV mutations provide resistance against ganciclovir?
UL54 - DNA polymerase - T460V
UL97 - Viral phosphotransferase
Which CMV mutations provide resistance against maribavir?
UL97 - Viral phosphotransferase - T409M
