Dr. Karatzios -- HIV Flashcards Preview

Block G -- Infection > Dr. Karatzios -- HIV > Flashcards

Flashcards in Dr. Karatzios -- HIV Deck (132)
1

Predominant mode of adult acquisition of HIV

Heterosexual intercourse

2

Predominent mode of childhood acquisition of HIV

Perinatal exposure

3

6 highly endemic areas for HIV

  • Sub-Saharan Africa
  • Southeast Asia (Thailand)
  • India
  • Haiti
  • China
  • Russia

4

How HIV enters cells (3 points)

  • HIV viral envelope protein (gp120)
  • Human T cell receptor
  • Human co-receptors (CCR5 or CXCR4 or both)

5

6 cells that HIV infects

  • CD4+ T lymphocytes
  • Dendritic cells (skin, lymph nodes, brain)
  • Macrophages
  • CD8+ T lymphocytes
  • NKC
  • Natural killer T cells (viral reservoir)

6

3 systems in which HIV lives

  • Lymphoid organs
  • CNS
  • Genitourinary system

7

3 lymphoid organs in which HIV can live

  • Peripheral lymph nodes
  • GI lymph nodes
  • Bone marrow

8

Method of transmission of HIV living in GI lymph nodes

Neonatal

9

How does HIV enter the CNS?

HIV Tat protein disrupts the BBB --> Microglial and dendritic cells

10

2 reservoirs of HIV replication

  • CNS
  • Genitourinary system

11

3 parts of the genitourinary system in which HIV can live

  • Semen
  • Renal epithelium
  • Marcophages and lymphocytes in cervix

12

How does HIV infect semen?

HIV crosses the blood-testis barrier

13

Why is there a high rate of genomic mutation in HIV?

Reverse transcriptase is extremely error-prone

14

2 types of genomic mutations that HIV may undergo?

  • Spontaneous mutations over time
  • Drug-driven mutations

15

2 potential outcomes of spontaneous HIV mutations

  • Many are silent/no-effect
  • Some confer resistance to medications

16

Compare wild type HIV to mutated HIV

  • Highly mutated = "less fit"
  • Wild type = easily transmissible and replicates more efficiently

17

When do mutants overtake wild type HIV?

  • If medications are failing --> mutants accumulate
  • Held in reserve and overtake wild type once medications restarted

18

When does wild type HIV overtake mutants?

Once medications are stopped

19

Effect of initial viremia from HIV

Infection of lymph nodes

20

Effect of secondary viremia from HIV

Mononucleosis-like illness

21

2 events occurring during the window period between initial and secondary viremia

  • Silent viral replication in lymph nodes
  • Little or no HIV antibodies

22

Length of window period between initial and secondary viremia

Up to 3 months

23

7 symptoms of acute HIV syndrome

Mononucleosis-like illness

  • Fever
  • Malaise
  • Non-exudative pharyngitis
  • Maculpapular rash (50%)
  • Myalgias
  • Headache
  • GI distress

24

5 signs of acute HIV syndrome

Mononucleosis-like illness

  • Generalized lymphadenopathy
  • Hepatosplenomegaly
  • Oral or vaginal thrush
  • Lymphopenia THEN acute lymphocytosis

25

Lab findings of acute HIV syndrome

  • HIV antibody negative
  • PCR and antigen positive

26

Timeline of acute HIV syndrome

  • 1 - 6 weeks after infection
  • Lasts up to 3 weeks
  • Spontaneous resolution
  • --> Window period

27

Main cell type destroyed by HIV

CD4+ T cells

28

3 ways CD4+ T cells are destroyed

29

Severe immune suppression by age (in No/mm3)

  • <12 months = <750
  • 1 - 5 years = <500
  • >6 years = <200

30

Describe the natural history of HIV disease

31

Use of HIV serology

Screening and confirmatory test in humans >18 months age

32

Use of HIV PCR

Screening and confirmatory test in humans < 18 months age

33

How to determine viral copy number

  • Viral RNA numbers expressed as number of copies/mL blood or log:
    • log 2 = 100 copies/mL
    • log 3 = 1000 copies/mL
    • < log 1.6 = <40 copies/mL = undetectable

34

4 infections associated with HIV disease

  • Sinopulmonary infections
  • Salmonellosis
  • Meningitis
  • Candidiasis

35

Cardiac problem associated with HIV

Cardiomyopathy

36

3 growth and sexual development issues related to HIV

  • Delayed
  • Decrease in testosterone/libido
  • Osteoporosis

37

3 neurological issues related to HIV

  • Cognitive delay
  • Encephalopathy
  • Dementia

38

Renal problem associated with HIV

HIV nephropathy

39

2 psychiatric issues related to HIV

  • Depression
  • ADHD

40

Proportion of AIDS patients with esophageal disease

1/3

41

6 typical symptoms of esophageal disease in HIV patients

  • Dysphagia
  • Odynophagia
  • Retrosternal pain
  • Nausea
  • Anorexia
  • Weight loss

NOTE: Usually indolent onset

42

2 causes of dysphagia and odynophagia in AIDS patient

  • Esophageal inflammation
  • Ulceration

43

Likely cause of HIV-associated idiopathic esophageal ulcers

HIV seen in lymphocytes and lamina propria

44

Biopsy findings of herpes virus esophagitis

Multinucleated giant cells

45

Which other kind of esophagitis does HIV-associated idiopathic esophageal ulcers resemble?

CMV esophagitis

  • Shallow ulcers
  • Inclusion bodies on biopsy

46

3 infectious oral lesions associated with AIDS

  • Herpes simplex
  • Oral hairy leukoplakia
    • EBV-related
    • Non-painful
  • Oral candidiasis (usually painful)

47

Oral neoplastic lesion associated with HIV/AIDS

Kaposi's sarcoma

48

Effect of HBV in HIV/AIDS (3)

  • Spontaneous reactivation seen in AIDS
  • 19x more likely to die if HIV/HBV co-infected
  • HBV does not influence HIV progression, however

49

3 causes of death in HIV/HBV co-infection

  • Cirrhosis
  • Live failure
  • Carcinoma

50

Effect of HCV in HIV/AIDS

  • 94x higher risk of mortality
  • HCV may affect progression of HIV

NOTE: All HIV+ patients should be screened for HCV

51

3 pharmacological causes of hepatitis in HIV/AIDS patients

  • Protease inhibitors 
  • NNRTI 
  • Antimycobacterial drugs

52

Protease inhibitor that can cause hepatitis and steatosis in HIV patients

Ritonavir

53

NNRTI that can cause hepatitis in HIV patients

Nevirapine

54

3 antimycobacterial drugs that can cause hepatitis in HIV patients

  • Rifampin
  • Rifabutin
  • INH

55

3 pharmacological causes of jaundice in HIV patient

  • Protease inhibitors (atazanavir)
  • Septra
  • Macrolides

56

2 pharmacological causes of steatosis in HIV patients

  • Mitochondrial toxicity and lactic acidosis (i.e. NRTI such as ZDV, d4T, ddI)
  • Protease inhibitors (ritonavir)

57

2 common general causes of diarrhea in HIV/AIDS patients

  • Colitis
  • Malabsorption

NOTE: There are many causes and this affects 95% of patients in 3rd world with a 72% 10-mo mortality (chronic diarrhea)

58

5 bacterial causes of diarrhea in HIV patients

  • SSCYE, Listeria monocytogenes
  • Mycobacterium avium complex
    • Obstructive as well
  • Mycobacterium tuberculosis
    • Obstructive as well
  • Toxin-mediated (i.e. C. difficile)
  • Bacterial overgrowth

59

5 viral causes of diarrhea in HIV patients

  • CMV
  • Adenovirus
  • Rotavirus
  • HIV
  • Other causes of viral gastroenteritis

60

6 parasitic causes of diarrhea in HIV patients

  • Giardia lamblia
  • Cryptosporidium parvum
  • Microsporida
  • Isospora belli
  • Cyclospora cayetanensis
  • Entamoeba histolytica

61

Fungal cause of diarrhea in HIV patients

Histoplasma capsulatum

62

4 risk factors for diarrhea in HIV patients

  • Severe immunosuppression
  • Environmental conditions
  • Travel-related exposures
  • MSM

63

2 pharmacological causes of diarrhea in HIV patients

  • Most all antiretrovirals
  • Antibiotics

64

3 immune-mediated causes of diarrhea in HIV patients

  • IBD
  • Immune Reconstitution Syndrome
  • Celiac disease

65

2 neoplastic causes of diarrhea in HIV patients

  • Intestinal lymphoma
  • Kaposi's sarcoma

66

3 reasons why HIV-associated enteropathy may be due to HIV itself

  • Direct alteration of enterochromaffin cell function
  • Enterocyte degeneration
  • Microtubular depolymerization

67

2 results of HPV disease in setting of HIV

  • Anal condillomatosis
  • Cervical/Anal cancer

68

3 bacteria involved in sexually transmitted proctitis

  • Chlamydia trachomatis
  • Neisseria gonorrhea
  • Treponema pallidum

69

7 opporunistic infections in the setting of AIDS

  • Pneumocystosis jiroveci
  • Toxoplasma gondii
  • Candida esophagitis/moniliasis
  • CMV
  • Disseminated vericella zoster
  • Mycobacterium avium intercellulare
  • JC virus/Progressive multifocal leukoencephalopathy

70

4 non-opportunistic infections associated with AIDS

  • Salmonellosis
  • Crypto/microsporidiosis
  • Isospora belli
  • Giardia lamblia

71

3 neoplastic transformations in the setting of AIDS

  • HHV-8: Kaposi sarcoma
  • Castleman disease
  • CNS lymphoma

72

Median duration of disease prior to HAART

7.8 years

73

Median duration of disease after HAART

>15 years

74

Most frequent opportunistic pathogen in AIDS patients

Pneumocystis jiroveci

75

4 symptoms and signs of pneumocystis jiroveci in AIDS patients

  • Fever
  • Cough
  • SOB
  • Hypoxia

NOTE: Can involve extra-pulmonary areas as well (liver)

76

4 primary prophylaxis options for pneumocystic jiroveci

  • Septra po
  • Dapsone
  • Atovaquone
  • Pentamidine

77

Patients to administer pneumocystic jiroveci prophylaxis (2)

  • All HIV+ children <1 year regardless of CD4 count
  • Older children and adults when CD4 <200 (or <15% of total lymphocytic count)

78

3 treatments of pneumocystic jiroveci

  • Septra (IV or po)
  • Systemic corticosteroids
  • Supplemental oxygen

79

Secondary prophylaxis for pneumocystic jiroveci

Septra until CD4 > 200 for 3 months

80

Define mycobacterium avium complex

Disseminated disease based in the GIT and reticuloendothelial system

81

3 symptoms of mycobacterium avium complex infection

  • Pulmonary disease
  • Fever
  • Weight loss

82

2 primary prophylaxis drugs for mycobacterium avium complex

  • Azithromycin
  • Clarithromycin

83

Patients to give primary prophylaxis for mycobacterium avium complex

  • Childen < 5 yo that are severely immunosuppressed
  • People >6 yo with CD4 < 50 cells

84

Treatment for mycobacterium avium complex

  • Macrolide + rifabutin
  • Other second-line drugs

85

Secondary prophylaxis for mycobacterium avium complex

Macrolide + rifabutin until CD4 >75 for 3 months

86

Effect of HIV on mycobacterium tuberculosis transmission

HIV patients can transmit this to other much more easily than non-HIV patients

87

5 effects of cryptococcus neoformans in setting of HIV/AIDS

  • Meningitis
  • Raised intracranial pressure
  • Necrotizing intracranial pressure
  • Necrotizing lymphadenitis (mediastinal, cervical)
  • Necrotizing pneumonitis
  • Skin abscesses

88

Treatment for cryptococcus neoformans

  • Amphotericin B + Fluconazole IV
  • Followed by fluconazole po for weeks to months

89

Length of secondary prophylaxis for cryptococcus neoformans

Usually lifelong

90

6 manifestations of CMV in setting of HIV/AIDS

  • Retinitis
  • Uveitis
  • Retinal detachment
  • Visual loss
  • Pneumonitis
  • Disseminated

91

7 opportunistic viruses in setting of AIDS

  • CMV
  • HSV
  • VZV
  • HHV-8
  • HBC
  • HCV
  • JCV

92

3 manifestations of toxoplasma gondii in setting of HIV/AIDS

  • Encephalitis
  • Seizures
  • Disseminated CNS lesions (ring enhancing)

93

Treatment for toxoplasmia gondii

Sulfadiazine + pyrimethamine + folinic acid (leucovorin)

94

Secondary prophylaxis for toxoplasma gondii

Sulfadiazine + clindamycin until CD4 > 200 for 3 - 6 months

95

4 drugs involved in Highly Active AntiRetroviral Therapy (HAART)

Combination therapy with

  • NRTI
  • NNRTI
  • PI (protease inhibitors)
  • FI (fusion inhibitors)

96

2 aims of HAART

  • Reduction of HIV viral load to undetectable levels
  • Elevation of CD4 Th lymphcyte counts

97

8 NRTIs

  • ZDV
  • 3TC
  • d4T
  • ddI
  • ddC
  • Abacavir
  • Emtricitabine
  • Tenofovir

98

4 combinations of NRTIs

  • COmbivir
  • Trizivir
  • Kivexa
  • Truvada

99

5 NNRTIs

  • Delaviridine
  • Efavirenz
  • Nevirpine
  • Etravirine
  • Rilpivirine

100

2 NNRTI combinations

Atripla

Complera

101

Fusion inhibitor drug

Efurvitide

102

FI mechanism

Inhibition of fusion of HIV with human cells (a salvage mechanism)

103

FI administration

Subcutaneous injection

104

2 newer classes of HAART drugs

  • Integrase inhibitors
  • Coreceptor antagonists

105

Integrase inhibitor mechanism

Prevent integration of pro-viral DNA into human chromosomal DNA

106

2 integrase inhibitors

Raltegravir (Isentress)

Elvitegravir

107

Coreceptor antagonist mechanism

Prevent binding of HIV onto human cells

108

Coreceptor antagonist drug

Maraviroc

109

How to boost antiretrovirals

Inhibition of liver cytochrome p450 enzymes that metabolize some antiretrovirals (PIs, elvitegravir)

110

Aim of cytochrome p450 inhibition in antiretroviral therapy

Increase levels of antiretrovirals in the blood and tissues for max efficiency

111

2 boosting agents for antiretrovirals

Low doses of ritonavir

Newer = cobicistat

112

2 problems with ritonavir (a PI)

GI side fx and hyperlipidemia

May drug-drug interaction because of p450 inhibition

113

Advantage of using cobicistat

Less side fx than ritonavir

114

CD4 count when HIV treatment is mandatory

<300 cells/mL

115

Viral load log when HIV treatment is mandatory

>5.0

116

4 obstacles to HIV treatment

  • Adherence to medication
  • Intolreance and toxicity due to medications
  • Metabolic complications due to medications
  • HIV resistance to antiretrovirals

117

Compare the viral load of neonates to adults

Initial higher viral load --> may take longer to become undetectable

118

Describe the progression of rapidly progressing HIV in children

  • Rapid destruction of immune system
  • AIDS before 5 years of age (<5 months)
  • 50% 5 year survival

119

5 manifestations of AIDS in children

  • Opportunistic infections
  • Failure to thrive
  • Hepatitis
  • Diarrhea
  • Neurocognitive deterioration

120

Describe the disease progression of slowly progressing HIV in children

  • Effective immune activity and viral suppression
  • Asymptomatic or lymphadenopathy/parotitis
  • 68% 5-y survival; 71% 6.5-y survival

121

3 main aspects of disease presentation of HIV in children

  • Growth failure
    • Decline in weight-growth velocity despite adequate nutrition
  • Progressive neurodevelopmental deterioration
  • LIP (lymphoid interstitial pneumonitis)

122

3 manifestations of LIP in children with HIV

  • Immune0mediated lymphocytic infiltration of lungs
  • Respiratory distress; hypoxia
  • Reticulonodular infiltrates

123

Treatment for LIP in HIV children

Corticosteroids

124

Opportunistic infection for children with HIV

Pneumocystis jiroveci pneumonia

125

6 live vaccines

  • MMR
  • Varivax
  • Yellow fever
  • Oral typhoid
  • Oral polio
  • Intranasal influenza

126

Vaccine recommendations for children with HIV (3)

In severely immunosuppressed:

  • Vaccines not effective (defer or re-immunize once reconstituted)
  • Live vaccines contraindicated until CD4 rises to normal levels
  • BCG absolute contraindication

127

5 methods of acquisition of HIV in children

  • Perinatal exposure
  • Blood product transfusion
  • Sexual abuse

Adolescent years:

  • Sexual intercourse
  • IV drugs

128

3 perinatal exposures that may cause children to contract HIV

  • Intrapartum especially
  • Postpartum (i.e. breastmilk)
  • Rarely in utero

129

4 measures to reduce mother-child transmission of HIV

  • Implementation of universal prenatal HIV counseling and testing
  • Antiretroviral treatment and prophylaxis
  • Scheduled C-section (in some cases)
  • Avoidance of breastfeeding

130

Main tool for reducing perinatal exposure HIV transmission

Universal informed opt-out screening for HIV infection in all pregnant women

131

3 highest risk infectious materials for HIV transmission

  • Concentrated lab HIV
  • Blood
  • Any fluid contaminated with blood

132

6 infectious materials of intermediate risk for HIV transmission

  • Semen
  • Vaginal secretions
  • CSF
  • Amniotic fluid
  • Pleural/pericardial/peritonial/synovial fluids
  • Human milk