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1

define AIDS

A secondary immunodeficiency syndrome resulting from HIV infection and characterized by opportunistic infections, malignancies, neurologic dysfunction and a variety of other syndromes

2

describe the HIV virus

-- HIV is a human retro-virus of the lentivirus group
-- HIV-1 most common cause of aids in the world (w. hemisphere, europe, central, south, & east africa)
-- HIV-2 more related to the simian retro viruses (less common & less pathogenic mostly isolated in west africa)

3

what part of the immune system is compromised?

the immune defect is quantitative and qualitative deficiency in the thymus derived t-lymphocytes (t4 population)
- this set of cells is defined phenotypically by the presence of cd4 surface molecules, which is the cellular receptor for HIV
- virtually any cell with this receptor can be infected
- HIV binds specifically and with a HIGH AFFINITY

4

HIV testing options

Elisa first, follow up with western blot and PCR if positive

Elisa
This is the first step of an HIV test. This test detects the presence of HIV antibodies in the blood. If the test is negative then the person is determined not to be HIV infected and testing stops there. If the test is positive the second step of the test is run to confirm the positive results of the first step.

Western Blot
This test is used to confirm the positive Elisa test results. The Western Blot test detects specific protein bands that are present in an HIV infected individual. In combination with a positive Elisa, a positive Western Blot is 99.9 percent accurate in detecting that HIV infection has occurred.

HIV PCR
The HIV PCR test detects specific Deoxyribonucleic Acid (DNA) and Ribonucleic Acid (RNA) sequences that indicate the presence of HIV in the genetic structure of anyone HIV infected. After HIV infection occurs, RNA and DNA from the HIV virus circulates in the blood. The presence of these DNA and RNA "pieces" indicates the presence of HIV virus.

5

clinical manifestations

group I acute infection = acute mononucleosis like syndrome characterized by fever, macular or papular rash, malaise, and lymphadenopathy

group II asyptomatic infection = chronically infected, serology positive, virus culture positive, no clinical manifestations (latent state)

group III persistent genralized lyphadenopathy = palpable enlarged (lymph nodes >1cm.) at two or more extrainguinal sites persisting for more than 3 months, all test results are positive

group IV other diseases = subgroup a constitutional disease
subgroup b neurological disease
subgroup c secondary infectious disease
subgroup d secondary neoplasm
subgroup e other conditions


6

CD4 count and HIV copies are ______ related

inversely

7

key CD4 count

under 400 starts to look bad

8

opportunistic infections at CD4 350 level ***

herpes simplex virus
TB
oral/vaginal thrush
herpes zoster (shingles)
non-hodgkins lymphoma
KAPOSI SACRCOMA

9

opportunistic infections at CD4 200 level ***

pneumocystis carinii penumonia (PCP pneumonia/ PNEUMOCYSTIC JIROVECI PNEUMONIA)
candida esophagitis
bacillary angiomatosis

10

opportunisitic infections at CD4 100 level ***

cryptococcal meningitis
AIDS DEMENTIA
toxoplasmosis encephalitis
progressive multifocal leukoencephalopathy
WASTING SYNDROME
cryptosporidium diarrhea

11

opportunistic infections at CD4 50 level

mycobacterium avium
cytomegalovirus infection

12

primary neutrophic manifestations

Encephalopathy 90%
Meningitis 10%
Myelopathy 12%
Myopathy
Neuropathy 10-50%

13

secondary lymphotrophic manifestations

Metabolic and toxic
Neoplasm's
Opportunistic
Vascular complications

14

describe encephalopathy

aka AIDS dementia complex

Loss of concentration, forgetfulness, slow thoughts

Motor symptoms: loss of balance , leg weakness,
Parkinson’s like: tremors, muscle rigidity, slowed movements

Exam (hyperreflexia, babinski’s, gait ataxia)

15

treatment neuropathies

Desipiramine (25-250mg.) @bedtime

Amytriptyline (25-150mg.) @bedtime

Mexilitine (600 to 1200mg/day)

Gabapentin (300 to 3600 mg/day)

16

the neuropathy resolves after discontinuation of medications ... what is it?

drug related distal symmetric polyneuropathy

- complication of vincristine, DDI, DDC, D4T

17

describe GB syndrome

--- acute monophasic form of inflammatory demyelinating polyneuropathy (acute progressive ascending)
-- weakness with areflexia which begins distally
-- limb weakness & areflexia are critical early findings
*** Maximal neurological dysfunction reached 1month

18

describe CIDP chronic inflammatory demyelinating polyneuropathy

- occurs during early stages of HIV infection
- motor symptoms developing slowly over several months
- minor sensory complaints & areflexia are common and may precede the motor weakness

19

assoc. with decrease in cd4

progressive lumbosacral polyradiculomyelopathy

lower extremity & sacral paresthesias followed by rapidly progressive flaccid parapesis

20

msk manifestations of AIDS

Psoriatic arthritis
Reiter’s
Myopathy
Tenosynovitis
Non-specific arthritis

21

keratoderma blenorrhagicum

mucocutaneous lesion assoc with reiter's syndrome

appears on leg

22

necrotizing mitochondrial myopathy

zidovudine myopathy

23

proximal muscle weakness

HIV related inflammatory myopathy

moderately severe, painless, progressive weakness of proximal muscles

24

most common AIDS myopathy

HIV RELATED INFLAMMATORY MYOPATHY

25

myasthenia gravis vs eaton lambert syndrome ***

both are characterized by fatigability
EL improves as the day progresses
MG strength is generally in the am.

26

you see a pt with really severe onychomycosis and tinea pedis unresponsive to standard of care tx

may consider HIV/AIDS

27

low extremity edema in HIV AIDS pt

Secondary to hypo-albuminemia due to poor nutrition, malabsorption, defective hepatic synthesis, increase in protein catabolism, or loss in protein due to intestinal kaposi’s

28

kaposi's of the venous system

PSEUDOTHROMBOPHLEBITIS
-- Signs and symptoms of dvt
-- Erythema , edema accompanied by exquisitley tender indurated cords