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HIV Flashcards

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1
Q

cells infected by HIV

A

CD4 T cells
macrophages
dendritic cells

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2
Q

HIV important glycoproteins and their function

A

gp120 - binds CD4 receptor and co-receptor (CXCR4 or CCR5)

gp41 - promotes fusion of viral and cellular membranes

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3
Q

Risk of MTCT - without intervention

  • with BF
  • with HAART
A

15-40% without intervention
15-29% from BF
<2% with HAART

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4
Q

Acute HIV infection - time after

A

3-10 weeks

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5
Q

AIDS definition

A

CD4<14%

AIDs defining illnesses (opportunistic infections)

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6
Q

Clinical manifestiations of CD4 >200

A 
usually asympt
		Skin	candida vaginitis / oral
			Oral hairy leukoplakia 
Seb derm
			Shingles
			KS			
		Ca	CIN/Cx Ca
			B cell lymphoma
		Haem	ITP
			anaemia
Resp 	Bact pneumonia
	Recurrent URTIs
	Pulm TB
Other	Neuropathy
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7
Q

Clinical manifestations of CD4 100-200

A 
can be asympt
		Resp	PCP
			Histoplasmosis / coccidiomycosis
			Military/extrapulm TB
			Cardiomyopathy
		Neuro	neuropathies / myelopathy
			Dementia
			PML
		Other	wasting
			NHL
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8
Q

Clinical manifestations of CD4 <100

A 
can be asympt
		Fungal	candida oesophagitis
			Cryptococcus
		Viral	disseminated CMV
		Bact	disseminated MAC
		Parasite	toxo
			Microsporidiosis
			Chronic cryptosporidiosis
		Ca	CNS lymphoma
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9
Q

Benefits of ART

A 
prevent OI, Ca
Alter/reverse course of existing OIs
Improve/preserve immune ftn
↓ Sx
↑ QOL
Restore hope
↓ transmission
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10
Q

NRTI - least to most toxic (roughly)

A 
Lamivudine 3TC
Emtricitabine FTC
Tenofovir TDF
Abacavir ABC
Zidovudine AZT
Didanosine ddI
Stavudine d4T
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11
Q

NRTIs active against hep B

A

lamivudine 3TC

tenofovir TDF

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12
Q

problem with abacavir (ABC) and how to prevent

A

hypersensitivity rxn 3-7% - mortality

predict with HLA-B5701 test

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13
Q

NRTI class toxicities

A 
mitochondrial toxicity - neuropathy, LA
lipodystrophy
myopathy
hepatitis
pancreatitis
hyperlipidaemia
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14
Q

Lactic acidosis RFs

A 
female
older age
high BMI
- esp d4T, ddI, combination +
- esp 1st 3/12 Rx
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15
Q

Lactic acidosis Sx

A 
A, N, V, AP
pancreatitis, hepatitis
SOB, arrhyth
multi-organ failure, death
= increased anion gap + lactate
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16
Q

Lactic acidosis management

A
  • obtain venous sample w/o tourniquet
  • stop ARV if symptomatic + high lactate
  • supportive Rx
  • no d4T, ddI or AZT in next regimen
  • routine monitoring not required
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17
Q

NNRTI class toxicities

A

rash

hepatotoxicity

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18
Q

NNRTI features

A

long half-life 2-3 wks
lots of drug interxns
not active vs HIV-2 or group O
risk resistance

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19
Q

preferred TB PI

A

efavirenz

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20
Q

Nevirapine risk and RFs for it

A 
hypersensitivity rxn (rash, hepatotoxicity)
- esp men with CD4>400, women CD4>250
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21
Q

benefits of boosting PIs with ritonavir

A 
increased PI level b/c of less metabolism from cyt p450 inhibition
fewer pills
more predictable efficacy and activity
lower toxicity
less resistance
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22
Q

preferred PI in pregnancy

A

lopinavir/ritonavir

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23
Q

IRIS DDx

A 
relapse
resistance
drug toxicity
new disease process
- Rx dilemma: stop/continue ART, stop/change OI Rx, anti-infly agent, immunosuppressives
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24
Q

risks of starting ARV at low CD4

A

higher risk OI
higher risk toxicity
non-AIDS related complications more common (CVD, Ca, liver, renal disease)

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25
ARVs to avoid in TB
PIs - interxn with rifampicin | NVP - use EFV instead (can use if needed)
26
Treatment failure WHO definition
Clinical - new/recurrent stage 4 condition (IRIS excluded) Immunological - fall of CD4 to baseline / 50% from peak Virological - VL >5000
27
Indications for TMP/SMX prophylaxis of toxo/PCP
``` CD4 not available - WHO stages 2,3,4 CD4 available - CD4<350 (LMIC) - WHO stages 3,4 Alt - all PLHIV ```
28
3 I's for HIV/TB
Intensified case finding for active TB Infection control for TB at all clinical encounters INH preventive treatment - latent TB prevalence >30% - all with documented latent TB
29
Meningitis in HIV pts - causes
``` cryptococcus TB syphilis bacterial - strep, listeria viral fungal lymphoma ```
30
CNS mass lesion in HIV pts - causes
``` Common - toxo * - tuberculoma - lymphoma Less common - cryptococcoma - PML - bacterial abscess - other (syphilis, tumor, Chagas, Nocardia, Aspergillus) ```
31
Rx crypto meningitis
ampho B + flucytosine / fluconazole 800mg | or flucyt+flucon 1200mg or flucon 1200mg
32
Rx cerebral toxo
pyrimithemine + sulfadiazine (+ folinic acid) | alt clind+pyrimeth, high dose TMP/SMX, dapsone, atovaquone
33
Radiologic characteristics of CNS masses in HIV
``` Enhancement with contrast - toxo (ring enhancing) - lymphoma (ring or diffuse enhancement) - tuberculoma (diffuse enhancement) Non enhancing - crypto -PML # lesions - toxo (multiple) - lymphoma (single / multiple) - tuberculoma (single / multiple) ```
34
5 min neuro screen: | strength ok but slow mentation
HIV dementia
35
5 min neuro screen: | cauda equina syndrome
CMV radiculitis
36
5 min neuro screen: | pain in feet, decreased DTRs
sensory neuropathy ('d' drugs)
37
seizures, focal deficits
toxo
38
subacute progressive deficits
PML
39
ICP elevation
crypto
40
most common cause of retinitis in AIDS
CMV
41
CMV retinitis lesions
2/3 unilateral 'cheese and ketchup' uveitis rare
42
CMV retinitis Rx
iv gangiclovir / PO valganciclovir if lesions not sight-threatening 2-3 wks follow with secondary prophylaxis
43
Common lung disease aetiologies in HIV
TB PCP (pneumocystis jiroveci) bacterial fungal
44
Commonest cause of bacterial pneumonia in HIV
pneumococcus (100x increased risk)
45
CXR in HIV
normal - PCP, TB, fungal, bronchitis Diffuse infiltrates - PCP, TB, fungal, KS, CMV, LIP Focal airspace - TB, fungal, bacterial, nocardia PTx - PCP Nodules/cavities - TB, fungus, staph, nocardia, rhodococcus, KS, endocarditis Adenopathy - TB, fungus, MAC, lymphoma Pleural effusion - TB, bacterial, KS, lymphoma, uremia, CHF, hypoalbuminaemia
46
Normal CXR in HIV lung disease
PCP TB fungal bronchitis
47
Diffuse infiltrates on CXR
``` PCP TB fungal KS CMV LIP ```
48
Focal lesions on CXR
TB fungal bacterial nocardia
49
PTx on CXR
PCP
50
Nodules / cavities on CXR
``` TB Fungus staph nocardia rhodococcus KS endocarditis ```
51
Adenopathy on CXR
TB fungal MAC lymphoma
52
Pleural effusion on CXR
``` TB bacterial KS lymphoma uraemia CHF hypoalbuminemia ```
53
Oesophageal disease in HIV - aetiology - sx - management
``` candida CMV HSV TB fungi cancer idiopathic - CD4 <100 - dysphagia / odynophagia, CP - empiric Rx candida (fluconazole 100-200mg 2/wks); EGD & Bx if no response ```
54
Diarrhoea etiology in HIV
``` TB MAC bacteria (salmonella, shigella, E coli, SI bact overgrowth) protozoa (crypto, isospora belli, microsporidium, giardia, cyclospora, E histolytica, strongyloides) fungi (histoplasmosis) virus (CMV, HSV) HIV (AIDS enteropathy) malignancies (KS, lymphoma) drugs (PIs, ABx) ```
55
Etiologies if large volume diarrhoea
small bowel disease - cryptosporidium - microsporidium - cystoisospora - giardia
56
Etiologies if small volume diarrhoea
colitis / proctocolitis - tenesmus, bld, mucus - shigella - campylobacter - C diff - HSV - CMV
57
Hepatobiliary disorders in HIV
``` Viral hepatitis OIs - MAC, TB, bartonella, endemic fungi Malignancies Drugs - HAART, anti-TB, ABx, statins, psy Cholangitis - MAC, crypto, microsp, CMV ```
58
Potential reasons for non infectious complications of HIV
``` chronic immune system stimulation chronic inflammation premature aging mitochondrial damage (esp d drugs, NRTIs) drug toxicity ```
59
Spectrum of HAND (HIV-associated neurocognitive disorder)
ANI - asympt neurocog impairment MND - minor neurocog disorder HAD - HIV-associated dementia
60
AIDS-defining cancers
Kaposi's sarcoma Primary CNS lymphoma NHL invasive Cx Ca
61
AIDS-associated cancers (not AIDS-defining)
primary effusion lymphoma | SCC conjunctiva
62
Cancers with increased incidence in HIV (not dependent on CD4)
``` liver cancer Hodgkin's disease anal cancer melanoma oropharyngeal cancer lung cancer ```
63
Cause of Kaposi's sarcoma
Human herpesvirus 8
64
Anaemia in HIV - frequency | - causes
``` 70-80% patients with advanced disease Anaemia of chronic disease Drugs - AZT, cotrim, dapsone, primaquine Infections - parvo B19, fungi, TB Nutritional - iron, folate, B12, scurvy, Cu Malignancies, myelodysplasia ```
65
Leukopenia in HIV - frequency | - causes
``` 50% patients with advanced disease Due to HIV Drugs - AZT, cotrim, sulfas, pyrimethamine, ganciclovir, ABx Infections - MAC, TB, fungi, parvo B19 Malignancies, myelodysplasia ```
66
Thrombocytopenia in HIV - frequency | - causes
40% patients - may be early sign of HIV Periph destruction due to autoantibodies - HIV, drugs BM probs - infections, malignancy
67
Bicytopenia / pancytopenia in HIV | - causes
``` Malignancies - lymphoma, KS Infections - TB, MAC, VL, parvo B19, histo, cocci, crypto Aplastic anaemia, myelodysplasia Nutritional Drugs ```
68
Dyslipidaemia in HIV - causes
HIV | ARVs - esp boosted PIs, also NRTIs, efavirenz
69
Why is CVD more common in HIV?
``` HIV - dyslipidemia - endothelial damage - vascular dysftn - chronic inflammation - procoagulant factors - lipodystrophy ART - dyslipidemia - endothelial dysftn - HT - insulin R - fibrinogen levels - lipodystrophy ```
70
Bone disease in HIV
``` High prevalence osteopenia (25-60%), osteoporosis (10%) Possible causes - HIV - cytokines - ARV - lifestyle - MN, hypogonadism, acidosis - vit D insufficiency - liver disease Increased # rate in HIv ```
71
Type of HIV most common in Western world
subgroup B, group M, type 1
72
Type of HIV most common sth Africa (worldwide)
subtype C, group M, type 1
73
Common toxicities with ARVs
AZT - anaemia Tenofovir - tubular toxicity (take for hep B) Lamivudine - lovely (& FTC) (like for hep B) Abacavir - allergy affecting life Efavirenz - effects on baby, eccentric dreams, excellent in TB Nevirapine - nukes the liver, hypersens, near-normal CD4 esp a prob
74
Important ARV components in hep B pts
TDF + lamivudine/emcitrabine
75
Cotrimoxazole prophylaxis - indications and benefits
WHO clinical stage 2,3,4 CD4<200 for PCP/toxo Benefits - reduced mortality by 50% in severely immune-suppressed HIV-infected adults initiating ART, for at least 72 weeks. - reduced malaria incidence in these pts
76
Most frequent life-threatening OI and leading cause of death in HIV
TB
77
Three Is strategy
Isoniazid preventive treatment (IPT) intensified case finding (ICF) for active TB TB infection control (IC) (pre-ART care setting)

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