SH Revision 3

Question 2

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

Answer 2

Question 3

Describe the length of time for TB treatment in an HIV infected individual [2]

Answer 3

Treatment is for a minimum of 6 months and is extended to 12 months if CNS disease.

Question 4

Describe the presentation of mycobacterium avium intracellulare (MAI) with HIV infection

Answer 4

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

Question 5

Describe the dx of HIV x MAI

Answer 5

• 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

Question 6

Treatment of HIV x MAI? [4]

Answer 6

TREATMENT:
Clarithromycin or Azithromycin + Ethambutol +/- Rifabutin

Ciprofloxacin sometimes used

Question 8

HIV x CMV causes which common complication? [1]

Which other complications does it cause? [5]

Answer 8

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)

Question 9

Describe the clinical features and fundoscopy results for CMV retinitis [2]

Answer 9

Visual impairment:
- painless visual loss
- floaters
- flashing lights

Fundoscopy:
- retinal haemorrhages and necrosis
- ‘pizza’ retina
- retinal detachment and uveitis in some cases

Question 10

Describe the GI manifestiations of CMV x HIV infection [4]

Answer 10

GI MANIFESTATIONS:
* Oral ulceration
* Oesophageal Ulcers-lower half oesophagus
* Duodenitis and Gastritis
* Colitis-bloody diarrhoea- owl’s eye inclusion bodies seen on histology

Question 11

Oral hairy leukoplakia is caused by infection by which pathogen? [1]

Describe the pattern of seen [1]

Answer 11

Oral hairy leukoplakia - EBV

White adherent patches on lateral border of tongue with characteristic ribbed appearance

Question 12

Infection from which of the following is the most common cause of diarrhoea in HIV patients?

Cytomegalovirus
Cryptosporidium
Mycobacterium avium intracellulare
Giardia

Answer 12

Infection from which of the following is the most common cause of diarrhoea in HIV patients?

Cytomegalovirus
Cryptosporidium
Mycobacterium avium intracellulare
Giardia

Question 13

How do you manage MAI [3]

Answer 13

Rifabutin, ethambutol and clarithromycin

Question 14

What are the typical clinical features of MAI [5]

In a HIV patient

Answer 14

fever
sweats
abdominal pain from lymphadenopathy
diarrhoea - from infection of the small bowel
There may be hepatomegaly and deranged LFTs

Question 15

What might indicate that secondary / shingles infection is occuring in HIV infected person? [1]
HIV x VZV tx? [1]

Answer 15

Multidermatomal VZV may occur in HIV

Tx: Valaciclovir 1g tds p.o.for 7 days

Question 16

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

Question 17

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]

Answer 17

herpes zoster ophthalmicus

Question 18

HIV, neuro symptoms, multiple brain lesions with ring enhancement in a question is most likely to indicate: [1]

Answer 18

Toxoplasmosis

Question 19

HIV, neuro symptoms, widespread demyelination in a question is most likely to indicate [1]

Answer 19

Progressive multifocal leukoencephalopathy

Question 20

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:

Answer 20

JC virus

Question 21

HIV, neuro symptoms, single brain lesions with homogenous enhancement in a question is most likely to indicate:

Answer 21

CNS lymphoma

Question 22

HIV, neuro symptoms, multiple brain lesions with ring enhancement in a question is most likely to indicate [1]

Answer 22

Toxoplasmosis

Question 23

Dx of MAI in HIV ptx? [3]

Answer 23

Diagnosis is made by blood cultures and bone marrow examination

Question 24

M Avium Intracellulare occurs when the CD4 count is

Any
200 - 500
100 - 200
50 - 100
< 50

Answer 24

M Avium Intracellulare occurs when the CD4 count is

50 - 100
< 50

(less than 100)

Question 25

TB reactivation occurs when the CD4 count is

Any
200 - 500
100 - 200
50 - 100
< 50

Answer 25

TB reactivation occurs when the CD4 count is

Any
200 - 500
100 - 200
50 - 100
< 50

Question 26

Cytomegalovirus retinitis occurs when CD4 count is

Any
200 - 500
100 - 200
50 - 100
< 50

Answer 26

Cytomegalovirus retinitis occurs when CD4 count is

Any
200 - 500
100 - 200
50 - 100
< 50

Question 27

Dx? [1]
Tx? [2]

Answer 27

Typical cerebral Toxoplasmosis – multiple ring-enhancing lesions
- Sulphadiazine + Pyramethamine

Question 28

Prophylaxis for TG in HIV patients? [2]

Answer 28

Dapsone + Pyramethamine

Question 29

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

Answer 29

Cryptococcus Neoformans
- Headache is most common

NB: all are symptoms

Question 30

Tx for Cryptococcus Neoformans? [1]

Prophylaxis? [1]

Answer 30

Rx - IV Amphotericin +/- Flucytoscine if severe

Prophylaxis Fluconazole

Question 31

Describe the clinical presentation of Progressive Multifocal Leucoencephalopathy [4]

Answer 31

Insidious onset of:
* Motor deficit
* Personality change
* Visual field
* Brainstem and cerebellar involvement

Question 32

Which malignancies are AIDS defining? [3]

Answer 32

Kaposi’s Sarcoma
Invasive Cervical Carcinoma
Non-Hodgkin’s lymphoma:
* Diffuse large B-cell lymphoma
* Burkitt’s lymphoma
* Primary central nervous system lymphoma

Question 33

Tx? [1]
PMH HIV

Answer 33

Typical Intracerebral Lymphoma - Single, non-enhancing lesion

Tx: Radiotherapy

Question 34

Which non-AIDS defining cancer has the biggest cancer risk in HIV? [1]

Answer 34

Anal

Question 35

Describe the features of PID

Answer 35

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

Question 36

Describe the investigations to perfom for PID [4]

Answer 36

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.

Question 37

Describe the management for PID

Answer 37

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

Question 38

Describe what is meant by Fitz-Hugh-Curtis syndrome [1]

How do you visualise and treat this? [1]

Answer 38

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.

Question 39

Describe the differential diagnoses and how you’d differentiate them from PID [3]

Answer 39

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