Teaching Clinic: HIV

Question 1

What is HIV?

Answer 1

* Retrovirus (RNA virus), genus Lentivirus, family Retroviridae
* failing immune system - life-threatening opportunisEc infecEon
* leads to AIDS CD4 <200
* Bodily fluid: blood, semen, vaginal fluid or breast milk
* Free virus particles or virus in infected immune cells

Question 2

What cells does HIV primarily infect?

Answer 2

Primarily infects: T helper cells, macrophages and dendritic cells (CD4 receptor; CCR5 receptor)

Question 3

Where is HIV subtype B and subtype C most commonly found?

Answer 3

• Subtype C common in Asians
• Subtype B common in US

HIV-1 is more virulent compared to HIV-2: cause of global pandemic

Question 4

What are the routes of transmission of HIV?

Answer 4

Question 5

Risk factors of HIV transmission

Answer 5

Question 6

Clinical course of infection

Answer 6

Some patients may die during initial HIV infection due to dramatically lowered CD4+ T lymphocyte

Question 7

Presentations of acute HIV infection

Answer 7

Question 8

AIDS definining conditions

Answer 8

Question 9

HIV antibodies testing

Answer 9

Question 10

Window period for HIV

Answer 10

Question 11

Treatment of HIV

Answer 11

Question 12

What are the major classes of HIV medications?

Answer 12

• Reverse transciptase inhibitors
  ◦ NRTI
  ◦ NNRTI drugs
• Integrase
• PI more side effect compared to other

Question 13

* 23M, Vietnamese prisoner
* IVDA
* Admitted 21/8/2006
*  Fever, 3 weeks
* Syphillis
* Cutaneous lesions: arms 2 weeks, face 3 days
* 4 kg weight loss
*  Poor appetite
* Denied chill, myalgia, cough or diarrhea
* Unwell and faEgue * T 38.2, pulse 84/min * Bilateral cervical LN * Numerous skin-colour cutaneous papules, with umbilicaEon * Face and both arms * Lesions on the buccal mucosa and sod and hard palates * Normal lungs and heart * Enlarged liver 2 cm below R costal margin
* WCC 2.2 (N 2.0, L 0.2) * Plt 185 * ALP 85, ALT 50, Bil 23 * 1. Abnormality? * 2. Differen/al diagnosis?

Answer 13

* Abnormality: severe lymphopenia
* Differentials:
– Penicillium marneffei infection
– Cryptococcus neoformans infection
– Molluscum contagiosum
– Bacillary angiomatosis

Question 14

How to treat penicillium marneffei?

Answer 14

Question 15

Case 2 * Man in his twenEes with HIV * Cough, fever and SOB * Unwell for 2 months * Cough with white sputum, poor appeEte and wt loss * Clinic visit 3 weeks ago: CXR normal, sputum culture -ve * Short course of anEbioEcs: no improvement * No pleuriEc chest pain, haemoptysis or leg swelling Past Medical Hx * HIV +ve; unknown CD4 count * No history of asthma * Smoked 10 cigareles per day Physical Examina/on * CachecEc * Mild respiratory distress * Body temp: 37.5C * Pulse: 126 beats/ min * Oral thrush with no LNs * Trachea deviated to R * Clear chest and absent breath sounds and hyperresonance to percussion L side * WC 6.4 L 0.2 CD4 78 * ABG: pH 7.47 pCO2 4kPa pO2 18kPa (2LO2)

Abnormalities? Differentials?

Answer 15

L-sided tension pneumothorax
* PneumocysEs jiroveci pneumonia * Pulmonary tuberculosis * Pulmonary cryptococcosis * Pulmonary Kaposi’s sarcoma * Chronic obstrucEve pulmonary disease

Start on HRMZ, chest drain clamped and removed 1 week
HAART started

Question 16

What is DDx?

Answer 16

Question 17

Case 7
* HIV & AIDS
* Profuse watery diarrhea
* CD4 40
* Foul smelling diarrhea
* No blood

What are the DDx?

Answer 17

Question 18

Case 8
- PR bleed
- Patient has family Hx of Crohn’s
- Went to Bangkok multiple months ago

Answer 18

Case 8
* Anti-HIV 1 +ve (EIA/ Western blot) * Doxycycline 100mg bid 3 weeks
* Anal swab culture: Chlamydia
* Ceftriaxone 250mg IMI x 1
* Anal & urethral swab NAT:
* Benzathine penicillin IMI
Chlamydia trachomatis DNA +ve
weekly x 3
* Anal swab culture: Neisseria
gonorrhoede
* VDRL 1:16
* Histology: granulation tissue, lymphocytic infiltration, no crypt abscess, proctitis
* Referred ITC
* CD4 362
* HIV 320,000 copies/mL
* Plan to commence Truvada and
Dolutegravir
* Repeat colonoscopy in 1 month, proctitis settled

LGV rare in developed world
*⁠ ⁠LGV: Chlamydia trachomatis
(except endemic in Africa, India,
serotypes L1, L2 (most
SEA and the Caribbean)
common), L3
*⁠ ⁠2003, cluster of LGV reported in * Diagnosis: culture/ NAT MSM in the Netherlands
*⁠ ⁠Screen for HIV, syphilis,
*⁠ ⁠MSM, Caucasian, presented
gonorrhoea and HSV
with proctocolitis, very high HIV co-intection rate
*⁠ ⁠Complications of LGV
proctocolitis: rectal stricture
*⁠ ⁠Multiple sexual contacts
*⁠ ⁠Causal sex gatherings
*⁠ ⁠71% met partners at sex-on-premises venues or sex parties
*⁠ ⁠23% met partners via internet