SH Revision 4 Flashcards
As a general rule, HIV regimens consist of [+]
What is the BHIVA recommendation drug regimens to start for HIV tx? [4]
As a general rule, regimens consist of:
Two nucleoside reverse transcriptase inhibitors (NRTIs)
A third agent, typically one of:
- Ritonavir-boosted protease inhibitor (PI/r)
- Non-nucleoside reverse transcriptase inhibitor (NNRTI)
- Integrase inhibitor (INI) - RECOMENDED
OR
- Dolutegravir + Lamivudine
This is the list of BHIVA preffered drug regimens to start
In theory; any of above can be used; but BHIVA slide is the.
Name examples for NRTIs [4] and NNRTIs [2]
NRTIs:
* Tenofovir disoproxil fumarate
* Abacavir
* Emtricitabine
* Lamivudine
NNRTIs:
- Efavirenz
- Nevirapine
As NRTIs are the backbone - don’t want to be LATE with starting treatment Lamivudine, Abacavir TDF Emtricitabine
Describe the MoA of PIs [1]
Protease inhibitors (PIs) inhibit the action of protease preventing the cleavage of Gag-Pol polyproteins.
PIs are given alongside which drug [1] as they boost the action of the drug
Name two examples of PIs
They are given alongside ritonavir - referred to as a boosted PI - which increase the action of the drug.
PIs:
* Atazanavir
* Darunavir
* Lopinavir
[] tend to have a high barrier to resistance and therefore may be preferred in patients where there are concerns regarding adherence
NRTIs
NNRTIS
PIs
II
EI
[] tend to have a high barrier to resistance and therefore may be preferred in patients where there are concerns regarding adherence
NRTIs
NNRTIS
PIs
II
EI
Post-attachment inhibitors prevent envelope protein [] engaging with co-receptors.
Name an example [1]
Post-attachment inhibitors prevent envelope protein glycoprotein-120 engaging with co-receptors.
There is currently one medication in this class, the monoclonal antibody Ibalizumab. It is given as an IV infusion once every two weeks.
Which drugs are contained in PEP? [2]
For how long is the course? [1]
Once a day of:
* Tenofovir disoproxil fumerate
* Two Raltegravir
for 28 days
State 3 side effects of protease inhibitors [3]
There are many adverse effects including lipodystrophy, hyperlipidaemia, insulin resistance and hepatotoxicity.
Which drugs are used in PrEP? [1]
Tenofovir-df/emtricitabine
How do you measure safety and toxicity of ARTs? [3]
- Renal and liver test
- Lipids and metabolic tests
- FBCs
Which ART might cause this reaction
Abacavir
Efavirenz
Tenofovir
Darunavir
Nevirapine
Which ART might cause this reaction
Abacavir - get HLAB5701 screen
Efavirenz
Tenofovir
Darunavir
Nevirapine
Which two drugs make up long-acting drugs for HIV treatment? [2]
II and NNRTI
Name two side effects of Tenofovir DF long term use [2]
Tenofovir DF:
- Tubular toxicity (prevents re-ab of certain solutes at PCT - risk of kidney failure
- Reduction in bone mineral density
Name a side effect of abacavir long term use [1]
Dyslipidaemia / atherosclerosis
Avoid in ptx with high risk CVD
Dolutegravir is which drug class? [1]
Integrase inhibitor
Which drug class is associated with Cushingoid appearances? [1]
AZT / old medications
Which drug is most likely to cause vivid dreams, and somnolence
Efavirenz
Emtricitabine
Lopinavir
Abacavir
Enfuvirtide (T-20)
Tenofovir
Atazanavir
Raltegravir
Ritonavir
Dolutegravir
Nevirapine
Which drug is most likely to cause vivid dreams, and somnolence
Efavirenz
Emtricitabine
Lopinavir
Abacavir
Enfuvirtide (T-20)
Tenofovir
Atazanavir
Raltegravir
Ritonavir
Dolutegravir
Which drug is most likely to cause diarrhoea, nausea
Hyperlipidaemia
Efavirenz
Emtricitabine
Lopinavir
Abacavir
Enfuvirtide (T-20)
Tenofovir
Atazanavir
Raltegravir
Ritonavir
Dolutegravir
Nevirapine
Which drug is most likely to cause diarrhoea, nausea
Hyperlipidaemia
Lopinavir (PI)
Which ART causes a risk of hypersensitivty? [1]
Which drug class does it belong to? [1]
Abacavir: hypersensitivity
- NRTI
Renal disease is caused by long term use of which ART? [1]
Tenofovir
Which ART causes a risk of hepatotoxicity? [1]
Which drug class does it belong to? [1]
Nevirapine NNRTI
Which ART can cause this reaction? [1]
Which drug class? [1]
Darunavir
- PI
NB: Reaction = SJS
Efavirenz can cause which side effects? [3]
Neuropsychotic / CNS side effects:
- impaired concentration
- mood swings
- sleep disturbance
Which drug is most likely to cause elevation in bilirubin (unconjugated)
Efavirenz
Emtricitabine
Lopinavir
Abacavir
Enfuvirtide (T-20)
Tenofovir
Atazanavir
Raltegravir
Ritonavir
Dolutegravir
Nevirapine
Which drug is most likely to cause elevation in bilirubin (unconjugated)
Atazanavir (PI)
Which drug is most likely to cause a severe reaction at the injection site
Efavirenz
Emtricitabine
Lopinavir
Abacavir
Enfuvirtide (T-20)
Tenofovir
Atazanavir
Raltegravir
Ritonavir
Dolutegravir
Nevirapine
Which drug is most likely to cause a severe reaction at the injection site
Efavirenz
Emtricitabine
Lopinavir
Abacavir
Enfuvirtide (T-20)
Tenofovir
Atazanavir
Raltegravir
Ritonavir
Dolutegravir
Which drug is most likely to cause mood / sleep disturbance and is an II?
Efavirenz
Emtricitabine
Lopinavir
Abacavir
Enfuvirtide (T-20)
Tenofovir
Atazanavir
Raltegravir
Ritonavir
Dolutegravir
Nevirapine
Which drug is most likely to cause **mood / sleep disturbance and is an II?*
Dolutegravir
Which drug is most likely to cause SJS
Efavirenz
Emtricitabine
Lopinavir
Abacavir
Enfuvirtide (T-20)
Tenofovir
Atazanavir
Raltegravir
Ritonavir
Dolutegravir
Nevirapine
Which drug is most likely to cause SJS
Nevirapine
Which drug is most likely to cause renal dysfunction
Efavirenz
Emtricitabine
Lopinavir
Abacavir
Enfuvirtide (T-20)
Tenofovir
Atazanavir
Raltegravir
Ritonavir
Dolutegravir
Nevirapine
Tenofovir
Which drug is most likely to cause reduced bone minderal density
Efavirenz
Emtricitabine
Lopinavir
Abacavir
Enfuvirtide (T-20)
Tenofovir
Atazanavir
Raltegravir
Ritonavir
Dolutegravir
Nevirapine
tenofovir
Which drug is most likely to cause an increased risk of CVD
Efavirenz
Emtricitabine
Lopinavir
Abacavir
Enfuvirtide (T-20)
Tenofovir
Atazanavir
Raltegravir
Ritonavir
Dolutegravir
Nevirapine
Which drug is most likely to cause an increased risk of CVD
Efavirenz
Emtricitabine
Lopinavir
Abacavir
Enfuvirtide (T-20)
Tenofovir
Atazanavir
Raltegravir
Ritonavir
Dolutegravir
Nevirapine
Which antiretroviral is most likely to be responsible for jaundice?
Abacavir
Atazanavir
Darunavir
Efavirenz
Emtricitabine/FTC
Lamivudine/3TC
Lopinavir
Nevirapine
Raltegravir
Ritonavir
Tenofovir
TMS
Atazanavir
Generalised itchy rash with raised liver enzymes 2-4 weeks into treatment is most likely? [1]
Nevirapine
Risk of weight gain seems to be higher with some ART agents:
- Tenofovir [] is associated with more weight gain than Tenofovir [], which may
be protective
Risk of weight gain seems to be higher with some ART agents:
- Tenofovir alafenamide (TAF) is associated with more weight gain than Tenofovir (TDF), which may
be protective
TAF –> FAT
[Drug class] are associated with more weight gain than other ART: Raltegravir >
Integrase Inhibitors are associated with more weight gain than other ART: Raltegravir >
[] tend to exacerbate the cytopenic effects of chemotherapy.
NNTRIS
NRTIs
IIs
PIs
FI
NRTIs tend to exacerbate the cytopenic effects of chemotherapy.
[] are potent liver enzyme inducers and may lower the levels of other drugs
NNTRIS
NRTIs
IIs
PIs
FI
[] are potent liver enzyme inducers and may lower the levels of other drugs
NNTRIS
NRTIs
IIs
PIs
FI
How should you manage infants born to HIV infected mothers? [1]
Most infants should be given AZT monotherapy for 4 weeks
When should an elective caesarean section should be planned for 38 weeks? [2]
Women on combination therapy with detectable viraemia
Women with HIV / HCV co-infection
For ART to be
successful, adherence rates must be in the range of []-[]%
For ART to be
successful, adherence rates must be in the range of 90-95%
35 yo man, CD4 count 500, right sided chest pleuritic chest pain and temperature of 38.5 degrees.
What is the most likely causative organisms?
Adenovirus
Aspergillus fumigatus
Cryptococcus neoformans
Cytomegalovirus
Haemophilus influenzae
Histoplasma capsulatum
Mycobacterium avium cellulare
Mycobacterium TB
Pneumocystis jiroveci
Pseudomonas aeruginosa
Staphylococcus aureus
Streptococcus pneumonia
Streptococcus pneumoniae
- This is because his CD4 is normal, so we immediately can cross out every cause of disease in low CD4
35 yo man, CD4 of 100, SOB on exertion and a temperature of 38
Adenovirus
Aspergillus fumigatus
Cryptococcus neoformans
Cytomegalovirus
Haemophilus influenzae
Histoplasma capsulatum
Mycobacterium avium cellulare
Mycobacterium TB
Pneumocystis jiroveci
Pseudomonas aeruginosa
Staphylococcus aureus
Streptococcus pneumonia
200 – cut-off for CD4 count when we start worrying about opportunistic infections
Answer: pneumocystis jiroveci – most common opportunistic respiratory infection in ppl with low CD4 count
35 yo lady from Zimbabwe, CD4 of 300, temperature of 37.8
Adenovirus
Aspergillus fumigatus
Cryptococcus neoformans
Cytomegalovirus
Haemophilus influenzae
Histoplasma capsulatum
Mycobacterium avium cellulare
Mycobacterium TB
Pneumocystis jiroveci
Pseudomonas aeruginosa
Staphylococcus aureus
Streptococcus pneumonia
Zimbabwe – high prevalence of TB & HIV (they overlap & are synergistic)
35 yo pigeon fancier, CD4 of 50, temperature 38
Adenovirus
Aspergillus fumigatus
Cryptococcus neoformans
Cytomegalovirus
Haemophilus influenzae
Histoplasma capsulatum
Mycobacterium avium cellulare
Mycobacterium TB
Pneumocystis jiroveci
Pseudomonas aeruginosa
Staphylococcus aureus
Streptococcus pneumonia
Cryptococcus neoformans
- Opportunistic fungal infection carried by birds
Forms space occupying lesions (clumps of fungus) in the lungs, brain, skin, eyes
NB - Mycobacterium avium intracellulare has nothing to do with birds, it is a water-born infection; put in exam question as a trap
35 yo injecting drug user, CD4 of 300, temperature 38
Adenovirus
Aspergillus fumigatus
Cryptococcus neoformans
Cytomegalovirus
Haemophilus influenzae
Histoplasma capsulatum
Mycobacterium avium cellulare
Mycobacterium TB
Pneumocystis jiroveci
Pseudomonas aeruginosa
Staphylococcus aureus
Streptococcus pneumonia
Staphylococcus aureus
Staph lives on skin normally, can cause problems if wound present, IV lines, IV injections
Characteristic thing on CXR à cavitating consolidations (air spaces)
40 yo man, returned from Thailand 2 months earlies, presents with generalised rash, systemic malaise, generalised lymphadenopathy and low-grade fever. Admits to unprotected sex with a girl he met in a bar in Bangkok.
Burkitts lymphoma
Chancroid
Epstein Barr virus
Genital herpes
Hodgkin’s lymphoma
Kaposi’s sarcoma
Lymphogranuloma venereum
Non Hodgkin’s lymphoma
Persistent generalised lymphadenopathy
Rubella
Sarcoidosis
Syphilis
Syphilis
Secondary syphilis rash –> Maculopapular rash, widely disseminated, non-itchy, red, involves palms and soles (which other rashes don’t) à not everybody gets it, depends on the immune response
Timecourse –> 4-6 weeks for secondary syphilis since exposure
25 yo man, recently diagnosed with HIV, prominent, non-tender glands in neck and axillae. Otherwise well with CD4 of 550 and viral load of 25000 copies per ml.
Burkitts lymphoma
Chancroid
Epstein Barr virus
Genital herpes
Hodgkin’s lymphoma
Kaposi’s sarcoma
Lymphogranuloma venereum
Non Hodgkin’s lymphoma
Persistent generalised lymphadenopathy
Rubella
Sarcoidosis
Syphilis
Persistent generalised lymphadenopathy (PGL)
Does not do anything, entirely benign
Can occur anywhere where lymph nodes are
Important to document that it is there
Sometimes goes away, sometimes does not
30 yo man, HIV+, malaise, weakness, anaemia. Low-grade fever and increasingly unwell over several weeks. CD4 of 100. CT scan reveals enlarged hilar and para-aortic lymph nodes.
Burkitts lymphoma
Chancroid
Epstein Barr virus
Genital herpes
Hodgkin’s lymphoma
Kaposi’s sarcoma
Lymphogranuloma venereum
Non Hodgkin’s lymphoma
Persistent generalised lymphadenopathy
Rubella
Sarcoidosis
Syphilis
30 yo man, HIV+, malaise, weakness, anaemia. Low-grade fever and increasingly unwell over several weeks. CD4 of 100. CT scan reveals enlarged hilar and para-aortic lymph nodes.
Non Hodgkin’s lymphoma
- most common lymphoma in HIV
40 yo man, multiple purple-brown lesions on the trunk and face. Oral lesions. HIV positive, CD4 of 53.
Cause?
Kaposi’s sarcoma
Can get it anywhere –>** tip of the nose is quite common, gut, viscera (e.g. lung), skin**
AIDS defining diagnosis
Caused by Human Herpes Virus 8 (HHV8) so Kaposi’s is a virally derived cancer
It is a cancer, but behaves like opportunistic infection
What is the next appropriate management step?
Why? [1]
Advanced HIV, headache, fever, recent grand mal seizure. CT head unremarkable.
Lumbar puncture
- Looking for cryptococcal meningitis.
Need to check CT head before lumbar puncture, because doing an LP on someone with raised ICP will kill the pt
What is the next appropriate management step?
Why? [1]
Pt with CD4 of 50, SOB, non-productive cough and fever. CXR normal.
Bronchoscopy and alveolar lavage
- Looking for PCP
- So majority of people will have abnormal CXR with this actually but this is not impossible; mean exam question
What is the next appropriate management step?
Why? [1]
IVDU, with HIV and hep C, AST twice the normal range.
Liver biopsy
What is the next appropriate management step?
Why? [1]
HIV+ pt, CD4 of 75, 2 right hemispheric lesions unchanged after 2 weeks tx with sulphadiazine and pyrimethamine (tx for toxoplasmosis)
Brain biopsy
- We don’t do biopsies lightly
Point is here, that you’ve made a diagnosis and it is not responding to treatment, so we need to find out what is going on
- This is likely to by a lymphoma
Brain lumps in HIV patients:
- Toxoplasmosis (multiple ring-enhancing lesions with swelling around them)
- lymphoma (single non-enhancing lesion)
Toxoplasmosis and lymphoma do not always fit text-book descriptions, they can look alike to each other at times
What is the next appropriate management step?
Why? [1]
HIV+ pt, CD4 of 25, severe retrosternal odynophagia, low grade fever, no oral candida.
Upper gastro-intestinal endoscopy
Looking for:
- Cytomegalovirus, Oesophageal candidiasis (but if not in the mouth, then unlikely to be further down the GI tract), Kaposi’s sarcoma (but does not usually cause pain)
Select the most likely diagnosis for pt with confusion.
47 yo man acting inappropriately for several months; uncharacteristically aggressive and moody. Stopped all antiretroviral dxs 6 months earlier, complaining of intolerable side effects. O/E apyrexial, no focal neurology. 7/10 MMSE with mistakes on memory questions. CD4 of 56, bloods normal. CT brain shows generalised cerebral atrophy and widened sulci. CSF pressure, cell count, protein, glucose, Z-N stain and India ink stain are all normal
Alcohol intoxication
CMV encephalitis
CNS lymphoma
Cryptococcal meningitis
HIV associated dementia
Progressive multifocal leukoencephalopathy
Toxoplasmosis
Tuberculosis meningitis
HIV associated dementia
Tx à restart antiretroviral therapy to get rid of viral replication in the brain; some ppl improve a bit, some will stabilise, for some it may have gone too far for any change; no specific dementia tx
32 yo lady from Zimbabwe, HIV+ diagnosed 4 wks before. 3 wk hx of worsening headache, neck pain with recent onset nausea and vomiting. O/E temperature 38.3 and mildly confused, photophobia, neck stiffness but no focal neuro signs. CT brain normal. CSF pressure is 30 cm H2O, analysis reveals 20 lymphocytes and positive India ink stain.
Alcohol intoxication
CMV encephalitis
CNS lymphoma
Cryptococcal meningitis
HIV associated dementia
Progressive multifocal leukoencephalopathy
Toxoplasmosis
Tuberculosis meningitis
Cryptococcal meningitis
Cryptococcus neoformans is a fungal organism, has a waxy coat on it. Has (+)-ve India ink stain, because of waxy coat it forms a halo around cell.
35 yo man, recently diagnosed HIV, presents to A&E having had a witnessed grand mal seizure as his 1st fit. Has just begun low dose Cotrimoxazole and planning to start anti-HIV therapy soon. CD4 is 60. R-sided limb weakness, extensor plantar reflex, confusion, temp 37.5. CT brain shows solitairy, left frontal lobe mass without contrast enhancement.
CNS lymphoma
HIV man, hasn’t visited clinic for a while, 3 wk hx of fatigue, malaise, increasing unsteadiness when stands up and when walking. CD4 is 50. O/E alert, afebrile, no motor weakness, wide based gait, imprecise heel-shin movement and past-pointing on finger nose test. CT brain mild diffuse cerebral atrophy, MRI brain shows extensive low attenuation signal of the cerebellar white matter without contrast enhancement or mass effect.
Alcohol intoxication
CMV encephalitis
CNS lymphoma
Cryptococcal meningitis
HIV associated dementia
Progressive multifocal leukoencephalopathy
Toxoplasmosis
Tuberculosis meningitis
Progressive multifocal leukoencephalopathy
No mass effect à not a space occupying lesion
Cause: reactivation of JC virus in brain because of immunosuppression
Infects the white matter (hence the name LEUKOencephalopathy)
42 yo woman, in A&E with her long term HIV+ partner. Presents with 1 month hx confusion, headache, difficulty watching TV, some injuries to her left arm caused by knocking into objects. O/E confused, low fever, oral candida, left eye temporal visual field defect and extensive perivascular exudates and haemorrhages on retinal examination. CT brain shows periventricular contrast enhancement and mild atrophy. She refuses lumbar puncture and is given presumptive treatment.
Alcohol intoxication
CMV encephalitis
CNS lymphoma
Cryptococcal meningitis
HIV associated dementia
Progressive multifocal leukoencephalopathy
Toxoplasmosis
Tuberculosis meningitis
42 yo woman, in A&E with her long term HIV+ partner. Presents with 1 month hx confusion, headache, difficulty watching TV, some injuries to her left arm caused by knocking into objects. O/E confused, low fever, oral candida, left eye temporal visual field defect and extensive perivascular exudates and haemorrhages on retinal examination. CT brain shows periventricular contrast enhancement and mild atrophy. She refuses lumbar puncture and is given presumptive treatment.
Alcohol intoxication
CMV encephalitis
CNS lymphoma
Cryptococcal meningitis
HIV associated dementia
Progressive multifocal leukoencephalopathy
Toxoplasmosis
Tuberculosis meningitis
