Final SH I Flashcards by patrick ellis

Describe brief overview of HIV immunoimpact

HIV affected cells:
* Reduced production of T cells (and all cells; pancytopenia common) – meaning naïve and memory cells in periphery
* Uncontrolled HIV replication occurs in naïve cells; causes chronic antigenic stimulation
* Get increased activated pool T cells and decreased memory, naïve T cells
* Having an activated pool of T cells targeted by HIV causes reduced replenishment of memory cells
* Become IC; and opportunistic infections occur

NB: the initial immune response is what causes first presentations of HIV

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gp120 binds to which receptors on T cells [2] and macrophages [2]

gp120 binds to CD4 and CXCR4 on T cells and CD4 and CCR5 on macrophages

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Diagnosis of primary HIV infection is primarily established through [], and a positive result must be confirmed using a second test.

Which further tests are given if a positive diagnosis is given? [+]

Diagnosis of primary HIV infection is primarily established through serum HIV enzyme-linked immunosorbent assay (ELISA), and a positive result must be confirmed using a second test.
- It detects both HIV-1 and HIV-2 antibodies as well as p24 antigen, a protein produced by the virus in early infection. A positive result warrants further testing to confirm the diagnosis.

Further tests:
* HIV-1/HIV-2 differentiation immunoassay
* HIV-1 viral load
* Genotypic resistance
* CD4+ T cell count
* Viral hepatitis serology
* Full STI screen (including syphilis serology)

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Patients at risk of HIV can request home testing kits, either

Self-sampling kits to be posted to the lab

Point-of-care tests

What do each of the following test? [2]

Patients at risk of HIV can request home testing kits, either:

Self-sampling kits to be posted to the lab:
- fourth-generation tests for anti-gp120 antibodies and the p24 antigen

Point-of-care tests:
- antibodies only

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Fourth-generation laboratory test for HIV checks for antibodies to HIV and the p24 antigen

It has a window period of [] days - what is the clinical significance? [1]

Point-of-care tests for HIV antibodies give a result within minutes. They have a [] day window period.

4th gen: 45 days:
- A negative result within 45 days of exposure is unreliable. More than 45 days after exposure, a negative result is reliable

Point-of-care tests for HIV antibodies
- give a result within minutes. They have a 90-day window period.

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Name and describe the two key tests in the monitoring of HIV are [2]

How often does testing happen? [1]

Viral load: (HIV RNA by PCR)
- the aim of treatment is to achieve an undetectable viral load (< 20 or < 50 copies of viral genome/mL blood depending on the test).
- After treatment is established and suppression is achieved (a period in which testing is more frequent), testing tends to be repeated every 6-12 months.

CD4 count:
- measured more frequently after a new diagnosis and in those with low CD4 counts.
- Once established on treatment with a suppressed viral load and two readings > 350 a year apart routine testing is not necessarily needed.

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Why are antibody test for HIV not useful in neonates? [1]

Which test should you perform [1] and at which time intervals? [3]

Antibody tests not useful in neonate because of presence of maternal antibody

HIV RNA PCR at:
* 1 - 3 days
* 4 - 6 weeks
* 8 - 12 weeks
HIV antibody at 18 months

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A patient is newly diagnosed with HIV.

Which tests [2] would you perform and when? [1]

HIV antibody
- at baseline and at 3 months

HIV RNA by PCR (viral load)

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Describe the treatment for oral / oesphogeal candida infection from HIV:

Topical tx [2]
Systemic tx [3]

Topical antifungals:
* Topical Nystatin / Amphoterecin lozenges
* Micanazole gel

Systemic antifungals (severe disease)
* Fluconazole 50-100mg/day
* If resistant e.g. long term use of Fluconazole or CD4< 50:
* Itraconazole
* IV Amphoteracin

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A patient with HIV suffers a pathology which is suspected to have arisen from inhaling a pathogen from bird faeces. What is the name of the pathogen? [1]

Cryptococcus Neoformans (CN)

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Cryptococcus Neoformans (CN) can impact which body systems? [3]

Describe the symptoms associated with each system being affected [+]

Skin:
- Umbilicated papules and ulceration

Lungs:
- Cough
- SOB
- Fever

Meninges & Brain:
- Asymptomatic (10%)
- Headache (most common symptom)
- Fever
- Mental change

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Describe how would investigate and diagnose cryptococcal meningitis (associated with HIV)

DIAGNOSIS :
Serum:
- Crytococcal Antigens (CrAg)

CSF:
- High pressure; low glucose
- Indian ink test positive
- CRAG
- culture +/- lymphocytes
- low glucose; high protein; high pressure

CT:
- meningeal enhancement
- cerebral oedema

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Describe the treatment for cryptococcal infection in HIV ptx:

Drugs [3]
Length [1]

IV Amphotericin
+/- Flucytoscine if severe

Then oral Fluconazole

Treat for 6 weeks minimum the repeat LP after this 6 weeks

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Which medication can be given for CN prophylaxis in HIV patients? [1]

PROPHYLAXIS: Fluconazole 200-400mg/ day.

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Prophylaxis for HIV x TG? [2]

Dapsone + Pyramethamine

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Dx of HIV x Cryptosporidium parvum? [2]

Tx? [1]

DIAGNOSIS:
Ziehl-Neelson staining of stool - may need up to 10
Rectal biopsy

TREATMENT:
* Difficult to eradicate if CD4 < 200, ART
* Paromomycin

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Dx of Microsporidium species X HIV? [1]

Tx? [3]

Microsporidium species:
- immunofluorescent staining of stool

TREATMENT
* ART
* Albendazole
* High dose Erythromycin

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Dx of Isospora belli x HIV? [1]

Tx [1]

DIAGNOSIS:
* Stool analysis

TREATMENT:
* Co-trimoxazole

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Dx of Aspergillus fumigatus x HIV? [1]

Tx [2]

Symptoms:
Cough, fever, dyspnoea

DIAGNOSIS:
Chest X-Ray - may see cavitation Bronchoscopy

TREATMENT:
* Amphoteracin B
* Itraconazole

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Dx of HIV x Histoplasma capsulatum (Histoplasmosis) [4]

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Chest X-Ray: diffuse infiltrates
Pancytopenia
Fungal blood cultures
Biopsies of affected tissue

Tx for HIV x Histoplasma capsulatum OR Penicillium marneffei (Histoplasmosis) [2]

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TREATMENT:
Itraconazole, Amphoteracin B

S&S of HIV x Histoplasma capsulatum (Histoplasmosis) [4]

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SYMPTOMS:
* Fever
* Constitutional symptoms
* Respiratory disease.

SIGNS:
* Hepato-splenomegaly, enlarged lymph nodes, chest signs 10% rash (resembles folliculitis or molluscum)
* Neurological signs

Progressive multifocal leukoencephalopathy occurs secondary due to an infection by which virus? [1]

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JC virus

A CD4 count < 50cells/mmÂ³ predisposes patients to which disorders due to infections from other pathogens [2]

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Cytomegalovirus retinitis
Mycobacterium avium-intracellulare infection

**[]** is a common complication of PCP State 3 extrapulmonary manifestations of PCP [3]

**Pneumothorax** is a common complication of PCP: * **hepatosplenomegaly** * **lymphadenopathy** * **choroid lesions**

Extensive or visceral KS may require systemic chemotherapy. Describe which drugs might be used to treat this [4]

**Bleomycin**, **etoposide** and **liposomal** **anthracyclines** and **paclitaxel** may be used.

Which types of NHL are associated with HIV [2]

**Large cell Lymphomas** (2/3) - usually EBV associated **Burkitt’s Lymphomas** (1/3), 40% are EBV positive

A patient is starting chemotherapy for their NHL associated with their HIV dx. Which three drugs should be initiated [3] to protect agaisnt which infections [3]

**Cotrimoxazole** - PCP **Azithromycin** - Mycobacterium Avium Intercellulare (MAI) **Fluconazole** - Candida

Describe the differences between MTB and MAI infection in HIV-Infected Individuals: - Area of body impacted - Response to treatment (fast/slow) - Late or early HIV involvement

Describe the length of time for TB treatment in an HIV infected individual [2]

Treatment is for a **minimum of 6 months** and is **extended to 12 months if CNS disease**.

Describe the presentation of mycobacterium avium intracellulare (MAI) with HIV infection

**SYMPTOMS**: * Fevers * Sweats * Weight loss * Fatigue * Anorexia * Infection in small bowel leads to **diarrhoea** and **malabsorption** * Abdominal lymphadenopathy causes **abdominal pain**. * Disseminated MAI is a common cause of **PUO in late-stage patients.** **SIGNS**: * May be none * Widespread lymphadenopathy * Hepatosplenomegaly

Treatment of HIV x MAI? [4]

TREATMENT: **Clarithromycin** or **Azithromycin** + **Ethambutol** +/- **Rifabutin** **Ciprofloxacin** sometimes used

HIV x CMV causes which common complication? [1] Which other complications does it cause? [5]

**Cytomegalovirus (CMV) retinitis** and **GI manifestations** **Adrenalitis** **Encephalitis** (detect CMV in CSF) **Polyradiculopathy** (ascending lower limb weakness with symmetrical sensory loss. **Multifocal neuropathy** (painful parasthesia and numbness in asymmetrical multifocal pattern)

Describe the clinical features and fundoscopy results for CMV retinitis [2]

**Visual** **impairment**: - painless visual loss - floaters - flashing lights **Fundoscopy**: - retinal haemorrhages and necrosis - 'pizza' retina - retinal detachment and uveitis in some cases

Describe the GI manifestiations of CMV x HIV infection [4]

GI MANIFESTATIONS: * **Oral ulceration** * **Oesophageal Ulcers**-lower half oesophagus * **Duodenitis** and **Gastritis** * **Colitis-bloody diarrhoea**- owl’s eye inclusion bodies seen on histology

How do you manage MAI [3]

Rifabutin, ethambutol and clarithromycin

What are the typical clinical features of MAI [5] | In a HIV patient

**fever** **sweats** **abdominal pain** from lymphadenopathy **diarrhoea** - from infection of the small bowel There may be **hepatomegaly** and **deranged LFTs**

What might indicate that secondary / shingles infection is occuring in HIV infected person? [1] HIV x VZV tx? [1]

**Multidermatomal** VZV may occur in HIV Tx: **Valaciclovir** 1g tds p.o.for 7 days

HEPATIC AND RENAL DISEASE IN HIV Describe the treatment of Hepatitis B and C and how this differs in the context of HIV co-infection Describe the spectrum of renal disease in HIV  Describe the investigation and management of abnormal renal function in an HIV- infected individual

A patient who is known to have HIV presents gradually worsening speech and behavioural problems associated with coordination difficulties. A MRI shows multifocal non-enhancing lesions is a stereotypical history for infection by:

**JC virus**

Dx of MAI in HIV ptx? [3]

Diagnosis is made by **blood cultures** and **bone marrow examination**

Prophylaxis for TG in HIV patients? [2]

Dapsone + Pyramethamine

A patient is found to have this with India ink staining. What is the diagnosis? [1] What is the most common symptom? Asymptomatic Headache Fever Mental change

**Cryptococcus Neoformans** - Headache is most common ## Footnote NB: all are symptoms

Tx for Cryptococcus Neoformans? [1] Prophylaxis? [1]

Rx - **IV Amphotericin** +/- Flucytoscine if severe Prophylaxis **Fluconazole**

Describe the clinical presentation of Progressive Multifocal Leucoencephalopathy [4]

Insidious onset of: * Motor deficit * Personality change * Visual field * Brainstem and cerebellar involvement

Which malignancies are AIDS defining? [3]

**Kaposi’s Sarcoma** **Invasive Cervical Carcinoma** Non-Hodgkin’s lymphoma: * **Diffuse large B-cell lymphoma** * **Burkitt’s lymphoma** * **Primary central nervous system lymphoma**

Describe the investigations to perfom for PID [4]

**NAAT swabs** - for gonorrhoea, chlamydia and Mycoplasma genitalium **HIV test** **Syphilis test** **A pregnancy test** should be performed on sexually active women presenting with lower abdominal pain to exclude an **ectopic pregnancy.** **Inflammatory markers (CRP and ESR)** are raised in PID and can help support the diagnosis.

Describe the differential diagnoses and how you'd differentiate them from PID [3]

**Endometriosis**: - Dyspareunia (pain during or after sexual intercourse); whereas **PID pain is constant** and not necessarily related to menstrual cycles. - **Pain** is more **present** with **dyspareunia** **deep** in the **pelvis** or **even lower back pain radiating down the legs.** - In contrast to PID, **physical** **examination** may reveal **nodules** or **tenderness** **posterior to the uterus** in the **pouch of Douglas** or along the uterosacral ligaments. **Ectopic Pregnancy**: - **Sudden** pain and **more** **severe** - Key differential: **amenorrhoea** - on **bimanual** **examination** there might be **adnexal tenderness** or a **palpable** **mass** on one side of the pelvis. **Acute Appendicitis**: - Starts at umbilicus and moves laterally (PID is bilateral pain) - more acute - Rebound tenderness

Final SH I Flashcards

(48 cards)