Section 6: HIV/AIDS Flashcards by Leonard Emuren

What are the major classes of antiretroviral drugs?

Nucleoside reverse transcriptase inhibitors (NRTIs)
Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
Protease inhibitors (PIs)
Fusion inhibitors (FIs)
Entry inhibitors
Integrase inhibitors

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Name 7 examples of NRTIs

Zidovudine (AZT)
Didanosine (ddI)
Abacavir
Emtricitabine (FTC) and lamivudine (3TC)
Tenofovir (TNV)
Stavudine

STD-ZEAL (use mneumonic)

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Name 5 examples of NNRTIs

Efavirenz (EFV)
Nevirapine (NVP)
Delavirdine (DLV)
Etravirine
Rilpivirine

Use mneumonic “N DEER”

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Name 5 examples of PIs

Atazanavir
Indinavir
Nelfinavir
Ritonavir
Saquinavir

Use the mnemonic RAINS to remember the PIs

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Major side effects of didanosine

Pancreatitis

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When to begin Rx with HAART?

In symptomatic patients (any CD4 or viral load)

In asymptomatic patients with a CD4 of 350 and any viral load

In pregnant women

In the setting of a needle stick involving blood from an HIV- patient.

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Common side effect of tenofovir

Renal toxicity

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Common side effect of zidovudine (AZT)

Myopathy

Bone marrow suppression (Anemia)

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Common side effect of abacavir

hypersensitivity reaction (e.g., fever, chills and dyspnea)

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Common side effect of emtricitabine (FTC) and lamivudine (3TC)

Diarrhea

Nausea

Headache

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Common side effect of protease inhibitors

Increase lipids, redistribute fat and cause DM

Hyperglycemia
Hyperlipidemia

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Common side effect of indinavir

Renal stones

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What is the indication and prophylactic Rx of PCP in HIV

CD4 count < 200

or previous hx of PCP

or oral thrush

Rx: TMP/SMX, dapsone or atovoquon

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What are the indication and prophylactic Rx of mycobacterium avium intercellulare (MAI) in HIV

CD4 < 50

Rx: azithromycin wkly

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What is the indication and Rx of toxoplasma gondii in HIV

CD4 < 100 and toxoplasma IgG +

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Name an example of fusion inhibitor

Enfuvirtide (T20)

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Common side effects of enfuvirtide (T20)

Injection site reactions

Diagnosis: HIV patient with shortness of breath, dry cough, hypoxia, and increased LDH.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1162-1163). . Kindle Edition.

PCP

PCP investigation:

Best initial diagnosis
Most accurate diagnosis

A chest x-ray will show increased interstitial markings bilaterally
Bronchoalveolar lavage

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1164-1166). . Kindle Edition.

Rx of PCP opportunistic infection in HIV patient

IV TMP/ SMX

If there is a rash, use IV pentamidine

Atovaquone can be used for mild pneumocystis

Dapsone is not intravenous and is used for prophylaxis, not treatment

If PCP is severe (pO2 < 70 or A-a gradient > 35), then give steroids

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1167-1171). . Kindle Edition.

Diagnosis: HIV positive patient with headache, nausea, vomiting, and focal neurologic findings.

What is the best initial test for above patient?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1173). . Kindle Edition.

Diagnosis: Toxoplamosis

Best initial test: head CT with contrast showing “ring” or contrast-enhancing lesions.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1174). . Kindle Edition.

Rx for toxoplasmosis

Pyrimethamine and sulfadiazine for 2 weeks and repeat the CT scan.

If the lesions are smaller, then this is confirmative of toxoplasmosis. If the lesions are unchanged in size, then perform a brain biopsy, since this is most likely lymphoma.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1175-1177). . Kindle Edition.

Daignosis: HIV with < 50 CD4 cells and blurry vision.

Rx for above patient

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1179-1180). . Kindle Edition.

Cytomegalovirus (CMV)

Rx: Ganciclovir or foscarnet (if resistant to ganciclovir)

Maintenance therapy is with oral valganciclovir lifelong, unless the CD4 goes up with HAART. If the CD4 rises, you can stop the CMV medications.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1183-1185). . Kindle Edition.

Diagnosis: HIV and < 50 CD4 cells with fever and headache.

Best initial test for above patient

Most accurate test for aove patient

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1187-1188). . Kindle Edition.

Cryptococcus

The best initial test is an India ink stain, which has about a 60 percent sensitivity.

The most accurate test is a cryptococcal antigen test, which is over 95 percent sensitive and specific.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1189-1191). . Kindle Edition.

Rx of cryptococcus

Treat initially with amphotericin, followed by fluconazole. The fluconazole is continued lifelong unless the CD4 count rises. If the CD4 count rises, all opportunistic infection treatment and prophylaxis can be stopped. Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1194-1196). . Kindle Edition.

Diagnosis: HIV and \< 50 CD4 cells with focal neurologic abnormalities. What is the best initial test for above patient? Rx for above patient Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1199-1200). . Kindle Edition.

Progressive Multifocal Leukoencephalopathy (PML) CT head or MRI brain: No ring enhancement is seen No specific Rx. Rx with HAART. PML resolves with improvement with HAART Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1198). . Kindle Edition.

Diagnosis: HIV and \< 50 CD4 cells. There is wasting with weight loss, fever, and fatigue. Anemia is frequent from invasion of the bone marrow. Increased alkaline phosphatase and GGTP with a normal bilirubin is characteristic of hepatic involvement. Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1205-1208). . Kindle Edition.

Mycobacterium Avium-Intracellulare (MAI) ## Footnote Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1204-1205). . Kindle Edition.

Diagnostic tests for MAI in descending order of sensitivity

Liver biopsy is the most sensitive. Bone marrow is more sensitive. Blood culture is the least sensitive. Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1209-1211). . Kindle Edition.

Rx for MAI

Clarithromycin and ethambutal

List the risk factors that place patients at greatest risk for developing candida endophthalmitis (? in HIV)

1. Central venous catheters 2. Total parenteral nutrition 3. Broad-spectrum antibiotic therapy 4. Prior abdominal suregery 5. Neutropenia 6. Corticosteroid therapy 7. Injection drug abuse

Rx of candida endophthalmitis

Vitrectomy and systemic antifungal (amphotericin B and/or flucanazole)

List some life threatening complications of HAART medications

* Immune Reconstitution Inflammatory Syndrome

Diagnosis: A paradoxical worsening of preexisting infections in HIV-positive individuals that occurs days to weeks after the initiation of Rx with highly active antiretroviral therapy (HAART). Best way to manage above condition (UW)

* Immune reconstitution inflammatory syndrome (IRIS) * IRIS is self-limited and is best managed with continued HAART and antibiotic Rx of the underlying pathogen (UW)

1 --- --- 2 --- can occur as an early manifestation of disseminated --- 3 --- in patients with HIV. It manifests as multiple, discrete, reddish colored papules with central umbilication

1. Cutaneous 2. Cryptococcosis 3. Cryptococcosis

Diagnostic test for cutaneous cryptococcosis

Histologic examination of the biopsy of the skin lesion

What is the Rx and duration of Rx of HIV-infected patients with late latent syphilis or latent syhpilis of unknown duration?

Benzantine penicillin G IM weekly for 3 weeks

What is the Rx of HIV-infected patients with early syphilis or early latent syhpilis (less than 1 year duration)?

Benzathine penicillin G IM as a single dose

How often should HIV-positive patients not already on HAART should have their CD4 count and viral load measured?

Every 3 to 4 months

In Rx-naive HIV-positive patient, HAART should decrease the viral load to ------ within 6 months

\<50 copies/mL

**Primary HIV-associated thrombocytopenia (PHAT)** affects approximately 40% of HIV positive patients at some point. * What is the Rx for PHAT? * What is the benefit of such Rx?

* Zidovudine * Reduces the occurence of opportunistic infections and Kaposi sarcoma

Which of the following skin disorders is pathognomonic for AIDS? * Seiborrheic dermatitis * Molluscum contagiosum * Pustular psoariasis * Bacillary angiomatosis * Oral candidiasis S95

**Bacillary angiomatosis** is a systemic disorder characterized by vascular tumors in patients with HIV/AIDS. When the tumors are seen in the skin they are called bacillary angiomatosis and in the liver they are called **bacillary peliosis hepatis**. In the skin it looks like Kaposi's sarcoma, hot unlike Kaposi's sarcoma, it is caused by the infectious organism Bartonella henselae. In hosts with normal immunity, Bartonella infection causes cat-scratch fever