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MD2 ID > HIV > Flashcards

HIV Flashcards

1
Q

Luke, 23 years old, presents with severe anal pain for 1 week
SHx: has been working on a cruise ship for the past month
O/E: anus appears normal, too tender to insert proctoscope, tender inguinal LNs
DDx?

A

Anal fissure
Thrombosed external haemorrhoids
IBD confined to rectum
Herpes simplex

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2
Q

Important aspects of Hx to ascertain with suspected STI/HIV

A

When do you last have sex?
Male or female partners?
Any anal or vaginal sex without a condom?
Partners from poorer countries?
Have you ever injected yourself with drugs or steroids?

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3
Q

Luke had receptive anal sex, without condoms, with several men on the cruise
Last sex was 10/7 ago
Ix?
Mx?

A

Anal swab for PCR for herpes simplex, Neisseria gonorrhoeae, Chlamydia trachomatis
Throat swab for N. gonorrhoeae PCR
First pass urine for Chlamydia trachomatis PCR
Serology for syphilis, HIV and hepatitis A/B
Treat suspected sexually-acquired proctitis for herpes, gonorrhoea and chlamydia at initial consultation, rather than waiting for results

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4
Q

What is the most common pathway of HIV transmission in Australia?

A

Anal sex

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5
Q

What is prevalence of HIV in homosexual men with casual partners?

A

~10%

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6
Q

When else should we consider HIV?

A

Disease commonly occurring with HIV or transmitted together

Clinical scenarios when it is important to know someone is HIV negative (e.g. pregnancy)

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7
Q

List 5 classical opportunistic infections seen in AIDS

A 
Cerebral toxoplasmosis
CMV retinitis
Cryptococcal meningitis
Pneumocystis pneumonia
Mycobacterium avium complex (MAC) infections
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8
Q

List 5 typical or severe skin or oral infections which may suggest the presence of HIV/AIDS

A

Shingles in a young person
Intra-oral warts, widespread facial warts, severe anogenital warts
Severe or widespread herpes simplex
Facial molluscum contagiosum
Oral candidiasis, oral hairy leukoplakia, necrotising gingivitis

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9
Q

What other infection may be seen in an AIDS patient?

A

TB

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10
Q

List 3 cancers more commonly seen in HIV?

A

Lymphomas
Kaposi’s sarcoma
Anal cancer

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11
Q

List 8 scenarios in which HIV should be considered as a diagnosis

A

Classical opportunistic infections
Atypical or severe skin or oral infections (esp if risk factors)
TB
Cancers
Unexplained weight loss (esp if risk factors)
Infections with the same risk factors as HIV
High-risk exposure, high-prevalence populations
When transmission can be prevented (e.g. pregnancy, organ or blood donation, needlestick injury)

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12
Q

List some infections which have the same risk factors for acquisition as HIV

A 
Other STIs (e.g. syphilis, gonorrhoea, anal STI in men, STI acquired abroad)
Hepatitis B or C
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13
Q

What tests can be used to assess for HIV Ab?

A

EIA

Western blot

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14
Q

List 4 key messages to give a newly-diagnosed HIV patient

A

You have HIV, not AIDS
HIV is readily treatable, with only moderately increased risk of some diseases or complications; you may outlive your doctor
It should not interfere with your future plans; you will need to schedule regular medical checks
Use condoms - may only require brief mention on day one, but safer sexual practices should be discussed in some detail when the patient is ready for this

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15
Q

Describe the pathophysiology and natural Hx of untreated HIV

A

HIV infects and destroys CD4+ immune cells (monocytes, macrophages, glial cells, CD4+ T lymphocytes)
Gradually CD4+ cells are depleted faster than they are produced
Cell-mediated immunity is weakened, affecting tumour surveillance and suppression of existing and new infections
In the earlier stages (CD4+ 200-500 cells/uL), patients are often asymptomatic or they may notice worse-than-usual skin or oral conditions e.g. tinea pedis, folliculitis, warts, genital herpes
AIDS-defining illnesses are rare at CD4+ counts >200 and more common

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16
Q

List 4 key questions to ask at time of HIV diagnosis

A

Have you donated blood/semen in the last year?
Are any sexual partners from the last year contactable? Could you call them and recommend a test?
Who can you talk to for support?
Ask about symptoms of seroconversion illness as this may give a clue to the duration of infection (e.g. fever, sore throat, rash, diarrhoea, LOW)

17
Q

How long after transmission does the HIV Ab test convert from negative to positive?

A

3-5 weeks

18
Q

When does HIV seroconversion illness occur?

A

Usually ~3-5 weeks after transmission (around same time the Ab test becomes positive; a good description of a seroconversion illness suggests infection occurred about a month previously)

19
Q

What are the symptoms of HIV seroconversion illness? How severe is this illness?

A 
Fever
Sore throat
Rash
Diarrhoea
LOW
Can be severe enough to prompt presentation to hospital, often presumed to be flu or glandular fever
20
Q

Luke has no recollection of seroconversion symptoms
You perform further tests and he returns for further discussion a few days later
How should Luke be assessed?

A

1) SHx: work, relationships, accommodation, mood, drug/alcohol/tobacco use
2) Sexual transmission risks (STI screening)
3) Check for co-infections e.g. TB (consider CXR, TB y-IFN assay), hep B and C (serology)
4) Examine for skin/mouth/anogenital infections, TB or cancers
5) Record weight
6) CD4+ T cell count
7) HIV viral load and genotype sequencing for drug-resistance mutations

21
Q

What signs of infections or cancers may be seen on the skin, mouth or anogenital region in HIV patients?

A

Kaposi’s sarcoma (skin or palate)
LN enlargement
Anal cancer (mostly in gay men)
Cervical cancer (in women)

22
Q

Describe the relationship between CD4+ T cell counts and immunosuppression in AIDS

A 
>500 = normal
200-500 = mild immunosuppression
23
Q

What factors should be taken into account when making a decision to initiate HIV treatment?

A

What is the safest option for Luke? (In terms of AIDS prevention, maximising chance of viral suppression and prevention of serious non-AIDS events)
Safest option for population (controlling risk of transmission to a known seronegative partner and/or casual partners)

24
Q

Luke, 27 year old with known HIV, returns from travelling the world with a bit of a cough
Has a new teaching job
Sx: dyspnoea with speaking, LOW, cough
O/E: temperature 37.8, some scattered crackles and wheezes
Has not had blood tests for 18 months
DDx?
Which common AIDS pneumonia presents in this way?

A

Always consider causes NOT related to HIV e.g. asthma
Viral URTI
Pertussis
Bacterial pneumonia (more common in HIV; Pneumocystis jiroveci pneumonia is an AIDS pneumonia which presents in this way)
Pulmonary TB (more common in HIV)

25
Q

How is PCP treated?

A

Cotrimoxazole

26
Q

Cotrimoxazole

A

Mixture of sulphamethoxazole (sulfonamide bacteriostatic Abx) and trimethoprim

27
Q

What are the principles of ART?

A

Suppress viral replication
Adequate suppression requires enough potent drugs (usually three) that a person can tolerate and remember to take e.g. a few pills once a day
Increased likelihood of immune reconstitution if ART started at CD4+ >200 cells/uL
Lifelong viral suppression appears better than intermittent therapy even at higher CD4 counts

28
Q

What are the goals of suppression of viral replication in HIV?

A

Prevent viral infection of CD4+ cells
Allow reconstitution of cell-mediated immunity
Stop reverse transcriptase generating random drug-resistant mutations

29
Q

What are the principles of ART in practice?

A

1) Aim for 100% adherence; ask patients regularly, deal with SEs
2) ART is all or nothing; don’t just stop one drug in the combination and continue the others
3) Beware interactions with protease-inhibitors (e.g. ritonavir) and NNRTI drugs (e.g. efavirenz)
4) Monitor viral load (should fall quickly and stay

30
Q

Luke has a lump in his neck, a month after starting treatment
Initially not visible but 2cm across, firm, behind left angle of mandible
You request an U/S-guided biopsy
Where should the specimens be sent and in what medium, and for what tests?

A

Biopsy specimens usually sent for histopathology in formalin, and some of this specimen should be, but nothing can be cultured from formalin; ensure some is sent in saline for mycobacterial culture and PCR
Request acid-fast stains

31
Q

What is the immune reconstitution inflammatory syndrome? In which infections is this most commonly seen?

A

When cell-mediated immunity improves, some weeks after starting ART, asymptomatic infections may suddenly present with inflammation
Symptoms occurring some weeks after starting ART, in a person with initially low CD4+ (usually

32
Q

For some months things go well; Luke’s PCP and his immune reconstitution MAC lymphadenitis are controlled and his CD4+ count rises >200
He has been on treatment for 9/12 and the HIV unit are happy with his progress
He is coming in to see you for a routine visit to collect more medications
What should you cover in the consultation? What test would you NOT want to forget?

A

1) Work, relationships, accommodation
2) Mood, drug/alcohol/tobacco use
3) Sexual transmission risks (STI testing)
4) Check for co-infections (e..g TB, hepatitis B and C serology)
5) Examine for signs of cancers or TB
6) Adherence to medication
7) SEs and monitoring toxicities
8) HIV viral load is the most important test in a patient on antiretrovirals (CD4+ T cell count worth knowing, esp if

33
Q

Luke’s results include a HIV viral load of 643 RNA copies/mL

What could be going on here? What is the cause of an elevated viral load?

A

Rising viral loads = non-adherence/resistance

34
Q

Summary of procedures for newly Dx or untreated patients

A

Reassure: good prognosis
At time of Dx, excluse recent past blood/semen donations
Encourage/organise testing of recent contacts
CD4+ T lymphocyte count (risk of AIDS if

35
Q

In patients on antiretroviral treatment, what should be monitored?

A

HIV viral load (should be

36
Q

What are the principles of adjusting ART?

A

Avoid drug holidays unless essential

Okay to replace one drug with another if viral load

MD2 ID (8 decks)

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