SH Revision 3 Flashcards
Describe the differences between MTB and MAI infection in HIV-Infected Individuals:
- Area of body impacted
- Response to treatment (fast/slow)
- Late or early HIV involvement
Describe the length of time for TB treatment in an HIV infected individual [2]
Treatment is for a minimum of 6 months and is extended to 12 months if CNS disease.
Describe the presentation of mycobacterium avium intracellulare (MAI) with HIV infection
SYMPTOMS:
* Fevers
* Sweats
* Weight loss
* Fatigue
* Anorexia
* Infection in small bowel leads to diarrhoea and malabsorption
* Abdominal lymphadenopathy
causes abdominal pain.
* Disseminated MAI is a common cause of PUO in late-stage patients.
SIGNS:
* May be none
* Widespread lymphadenopathy
* Hepatosplenomegaly
Describe the dx of HIV x MAI
- Bone marrow involvement leads to cytopenia, especially red cell hypoplasia.
- Anaemia, pancytopaenia
- Raised ALP
- Low albumin
- Radiology shows intra-abdominal lymphadenopathy
- Blood cultures x 3 at least, using special Bactec bottles, bone marrow.
- Culture of organism from a sterile site (bone marrow, blood, lymph node) is a surer sign of disease than
Treatment of HIV x MAI? [4]
TREATMENT:
Clarithromycin or Azithromycin + Ethambutol +/- Rifabutin
Ciprofloxacin sometimes used
HIV x CMV causes which common complication? [1]
Which other complications does it cause? [5]
Cytomegalovirus (CMV) retinitis
and
GI manifestations
Adrenalitis
Encephalitis (detect CMV in CSF)
Polyradiculopathy (ascending lower limb weakness with symmetrical sensory loss.
Multifocal neuropathy (painful parasthesia and numbness in asymmetrical multifocal pattern)
Describe the clinical features and fundoscopy results for CMV retinitis [2]
Visual impairment:
- painless visual loss
- floaters
- flashing lights
Fundoscopy:
- retinal haemorrhages and necrosis
- ‘pizza’ retina
- retinal detachment and uveitis in some cases
Describe the GI manifestiations of CMV x HIV infection [4]
GI MANIFESTATIONS:
* Oral ulceration
* Oesophageal Ulcers-lower half oesophagus
* Duodenitis and Gastritis
* Colitis-bloody diarrhoea- owl’s eye inclusion bodies seen on histology
Oral hairy leukoplakia is caused by infection by which pathogen? [1]
Describe the pattern of seen [1]
Oral hairy leukoplakia - EBV
White adherent patches on lateral border of tongue with characteristic ribbed appearance
Infection from which of the following is the most common cause of diarrhoea in HIV patients?
Cytomegalovirus
Cryptosporidium
Mycobacterium avium intracellulare
Giardia
Infection from which of the following is the most common cause of diarrhoea in HIV patients?
Cytomegalovirus
Cryptosporidium
Mycobacterium avium intracellulare
Giardia
How do you manage MAI [3]
Rifabutin, ethambutol and clarithromycin
What are the typical clinical features of MAI [5]
In a HIV patient
fever
sweats
abdominal pain from lymphadenopathy
diarrhoea - from infection of the small bowel
There may be hepatomegaly and deranged LFTs
What might indicate that secondary / shingles infection is occuring in HIV infected person? [1]
HIV x VZV tx? [1]
Multidermatomal VZV may occur in HIV
Tx: Valaciclovir 1g tds p.o.for 7 days
HEPATIC AND RENAL DISEASE IN HIV
Describe the treatment of Hepatitis B and C and how this differs in the context of HIV co-infection
Describe the spectrum of renal disease in HIV
Describe the investigation and management of abnormal renal function in an HIV- infected
individual
A man who is on treatment for HIV presents with a painful, vesicular rash on the right side of his face around the eye. Fluorescein staining reveals multiple small defects on the right cornea is a stereotypical history of: [1]
herpes zoster ophthalmicus
HIV, neuro symptoms, multiple brain lesions with ring enhancement in a question is most likely to indicate: [1]
Toxoplasmosis
HIV, neuro symptoms, widespread demyelination in a question is most likely to indicate [1]
Progressive multifocal leukoencephalopathy
A patient who is known to have HIV presents gradually worsening speech and behavioural problems associated with coordination difficulties. A MRI shows multifocal non-enhancing lesions is a stereotypical history for infection by:
JC virus
HIV, neuro symptoms, single brain lesions with homogenous enhancement in a question is most likely to indicate:
CNS lymphoma
HIV, neuro symptoms, multiple brain lesions with ring enhancement in a question is most likely to indicate [1]
Toxoplasmosis
Dx of MAI in HIV ptx? [3]
Diagnosis is made by blood cultures and bone marrow examination
M Avium Intracellulare occurs when the CD4 count is
Any
200 - 500
100 - 200
50 - 100
< 50
M Avium Intracellulare occurs when the CD4 count is
50 - 100
< 50
(less than 100)
TB reactivation occurs when the CD4 count is
Any
200 - 500
100 - 200
50 - 100
< 50
TB reactivation occurs when the CD4 count is
Any
200 - 500
100 - 200
50 - 100
< 50
Cytomegalovirus retinitis occurs when CD4 count is
Any
200 - 500
100 - 200
50 - 100
< 50
Cytomegalovirus retinitis occurs when CD4 count is
Any
200 - 500
100 - 200
50 - 100
< 50
Dx? [1]
Tx? [2]
Typical cerebral Toxoplasmosis – multiple ring-enhancing lesions
- Sulphadiazine + Pyramethamine
Prophylaxis for TG in HIV patients? [2]
Dapsone + Pyramethamine
A patient is found to have this with India ink staining.
What is the diagnosis? [1]
What is the most common symptom?
Asymptomatic
Headache
Fever
Mental change
Cryptococcus Neoformans
- Headache is most common
NB: all are symptoms
Tx for Cryptococcus Neoformans? [1]
Prophylaxis? [1]
Rx - IV Amphotericin +/- Flucytoscine if severe
Prophylaxis Fluconazole
Describe the clinical presentation of Progressive Multifocal Leucoencephalopathy [4]
Insidious onset of:
* Motor deficit
* Personality change
* Visual field
* Brainstem and cerebellar involvement
Which malignancies are AIDS defining? [3]
Kaposi’s Sarcoma
Invasive Cervical Carcinoma
Non-Hodgkin’s lymphoma:
* Diffuse large B-cell lymphoma
* Burkitt’s lymphoma
* Primary central nervous system lymphoma
Tx? [1]
PMH HIV
Typical Intracerebral Lymphoma - Single, non-enhancing lesion
Tx: Radiotherapy
Which non-AIDS defining cancer has the biggest cancer risk in HIV? [1]
Anal
Describe the features of PID
Features
* lower abdominal pain
* fever
* deep dyspareunia
* dysuria and menstrual irregularities may occur
* vaginal or cervical discharge
* cervical excitation
* RUQ tenderness
Examination findings may reveal:
* Pelvic tenderness
* Inflamed cervix (cervicitis)
* Purulent discharge
Describe the investigations to perfom for PID [4]
NAAT swabs
- for gonorrhoea, chlamydia and Mycoplasma genitalium
HIV test
Syphilis test
A pregnancy test should be performed on sexually active women presenting with lower abdominal pain to exclude an ectopic pregnancy.
Inflammatory markers (CRP and ESR) are raised in PID and can help support the diagnosis.
Describe the management for PID
Give a combination of:
- A single dose of intramuscular ceftriaxone 1g (to cover gonorrhoea)
- Doxycycline 100mg twice daily for 14 days (to cover chlamydia and Mycoplasma genitalium)
- Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as Gardnerella vaginalis)
NB: due to the difficulty in making an accurate diagnosis, and the potential complications of untreated PID, consensus guidelines recommend having a low threshold for treatment
Describe what is meant by Fitz-Hugh-Curtis syndrome [1]
How do you visualise and treat this? [1]
Complication of pelvic inflammatory disease. It is caused by inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum
Causes RUQ pain
Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis.
Describe the differential diagnoses and how you’d differentiate them from PID [3]
Endometriosis:
- Dyspareunia (pain during or after sexual intercourse); whereas PID pain is constant and not necessarily related to menstrual cycles.
- Pain is more present with dyspareunia deep in the pelvis or even lower back pain radiating down the legs.
- In contrast to PID, physical examination may reveal nodules or tenderness posterior to the uterus in the pouch of Douglas or along the uterosacral ligaments.
Ectopic Pregnancy:
- Sudden pain and more severe
- Key differential: amenorrhoea
- on bimanual examination there might be adnexal tenderness or a palpable mass on one side of the pelvis.
Acute Appendicitis:
- Starts at umbilicus and moves laterally (PID is bilateral pain)
- more acute
- Rebound tenderness
