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HIV Flashcards

1
Q

CNS mass lesion in HIV pts - causes

A 
Common
- toxo *
- tuberculoma
- lymphoma
Less common
- cryptococcoma
- PML
- bacterial abscess
- other (syphilis, tumor, Chagas, Nocardia, Aspergillus)
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2
Q

Focal lesions on CXR

A

TB
fungal
bacterial
nocardia

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3
Q

Meningitis in HIV pts - causes

A 
cryptococcus
TB
syphilis
bacterial - strep, listeria
viral
fungal
lymphoma
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4
Q

5 min neuro screen:

pain in feet, decreased DTRs

A

sensory neuropathy (‘d’ drugs)

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5
Q

cells infected by HIV

A

CD4 T cells
macrophages
dendritic cells

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6
Q

5 min neuro screen:

cauda equina syndrome

A

CMV radiculitis

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7
Q

CXR in HIV

A

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

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8
Q

Diffuse infiltrates on CXR

A 
PCP
TB
fungal
KS
CMV
LIP
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9
Q

Rx cerebral toxo

A

pyrimithemine + sulfadiazine (+ folinic acid)

alt clind+pyrimeth, high dose TMP/SMX, dapsone, atovaquone

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10
Q

Nevirapine risk and RFs for it

A 
hypersensitivity rxn (rash, hepatotoxicity)
- esp men with CD4>400, women CD4>250
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11
Q

Spectrum of HAND (HIV-associated neurocognitive disorder)

A

ANI - asympt neurocog impairment
MND - minor neurocog disorder
HAD - HIV-associated dementia

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12
Q

preferred TB PI

A

efavirenz

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13
Q

ICP elevation

A

crypto

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14
Q

PTx on CXR

A

PCP

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15
Q

problem with abacavir (ABC) and how to prevent

A

hypersensitivity rxn 3-7% - mortality

predict with HLA-B5701 test

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16
Q

most common cause of retinitis in AIDS

A

CMV

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17
Q

Acute HIV infection - time after

A

3-10 weeks

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18
Q

Leukopenia in HIV - frequency

- causes

A 
50% patients with advanced disease
Due to HIV
Drugs - AZT, cotrim, sulfas, pyrimethamine, ganciclovir, ABx
Infections - MAC, TB, fungi, parvo B19
Malignancies, myelodysplasia
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19
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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20
Q

Indications for TMP/SMX prophylaxis of toxo/PCP

A 
CD4 not available
- WHO stages 2,3,4
CD4 available
- CD4<350 (LMIC)
- WHO stages 3,4
Alt - all PLHIV
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21
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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22
Q

3 I’s for HIV/TB

A

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

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23
Q

preferred PI in pregnancy

A

lopinavir/ritonavir

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24
Q

Hepatobiliary disorders in HIV

A 
Viral hepatitis
OIs - MAC, TB, bartonella, endemic fungi
Malignancies
Drugs - HAART, anti-TB, ABx, statins, psy
Cholangitis - MAC, crypto, microsp, CMV
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25
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) ```
26
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) ```
27
Lactic acidosis Sx
``` A, N, V, AP pancreatitis, hepatitis SOB, arrhyth multi-organ failure, death = increased anion gap + lactate ```
28
Etiologies if small volume diarrhoea
colitis / proctocolitis - tenesmus, bld, mucus - shigella - campylobacter - C diff - HSV - CMV
29
Clinical manifestations of CD4 <100
``` can be asympt Fungal candida oesophagitis Cryptococcus Viral disseminated CMV Bact disseminated MAC Parasite toxo Microsporidiosis Chronic cryptosporidiosis Ca CNS lymphoma ```
30
ARVs to avoid in TB
PIs - interxn with rifampicin | NVP - use EFV instead (can use if needed)
31
Lactic acidosis RFs
``` female older age high BMI - esp d4T, ddI, combination + - esp 1st 3/12 Rx ```
32
Benefits of ART
``` prevent OI, Ca Alter/reverse course of existing OIs Improve/preserve immune ftn ↓ Sx ↑ QOL Restore hope ↓ transmission ```
33
Pleural effusion on CXR
``` TB bacterial KS lymphoma uraemia CHF hypoalbuminemia ```
34
Common lung disease aetiologies in HIV
TB PCP (pneumocystis jiroveci) bacterial fungal
35
AIDS definition
CD4<14% | AIDs defining illnesses (opportunistic infections)
36
Commonest cause of bacterial pneumonia in HIV
pneumococcus (100x increased risk)
37
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 ```
38
AIDS-defining cancers
Kaposi's sarcoma Primary CNS lymphoma NHL invasive Cx Ca
39
Etiologies if large volume diarrhoea
small bowel disease - cryptosporidium - microsporidium - cystoisospora - giardia
40
seizures, focal deficits
toxo
41
Potential reasons for non infectious complications of HIV
``` chronic immune system stimulation chronic inflammation premature aging mitochondrial damage (esp d drugs, NRTIs) drug toxicity ```
42
Thrombocytopenia in HIV - frequency | - causes
40% patients - may be early sign of HIV Periph destruction due to autoantibodies - HIV, drugs BM probs - infections, malignancy
43
Cancers with increased incidence in HIV (not dependent on CD4)
``` liver cancer Hodgkin's disease anal cancer melanoma oropharyngeal cancer lung cancer ```
44
Lactic acidosis management
- 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
45
Treatment failure WHO definition
Clinical - new/recurrent stage 4 condition (IRIS excluded) Immunological - fall of CD4 to baseline / 50% from peak Virological - VL >5000
46
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 ```
47
NRTI class toxicities
``` mitochondrial toxicity - neuropathy, LA lipodystrophy myopathy hepatitis pancreatitis hyperlipidaemia ```
48
Cause of Kaposi's sarcoma
Human herpesvirus 8
49
Dyslipidaemia in HIV - causes
HIV | ARVs - esp boosted PIs, also NRTIs, efavirenz
50
AIDS-associated cancers (not AIDS-defining)
primary effusion lymphoma | SCC conjunctiva
51
subacute progressive deficits
PML
52
Clinical manifestations of CD4 100-200
``` can be asympt Resp PCP Histoplasmosis / coccidiomycosis Military/extrapulm TB Cardiomyopathy Neuro neuropathies / myelopathy Dementia PML Other wasting NHL ```
53
Adenopathy on CXR
TB fungal MAC lymphoma
54
CMV retinitis lesions
2/3 unilateral 'cheese and ketchup' uveitis rare
55
5 min neuro screen: | strength ok but slow mentation
HIV dementia
56
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 ```
57
HIV important glycoproteins and their function
gp120 - binds CD4 receptor and co-receptor (CXCR4 or CCR5) | gp41 - promotes fusion of viral and cellular membranes
58
NRTIs active against hep B
lamivudine 3TC | tenofovir TDF
59
NRTI - least to most toxic (roughly)
``` Lamivudine 3TC Emtricitabine FTC Tenofovir TDF Abacavir ABC Zidovudine AZT Didanosine ddI Stavudine d4T ```
60
Rx crypto meningitis
ampho B + flucytosine / fluconazole 800mg | or flucyt+flucon 1200mg or flucon 1200mg
61
Risk of MTCT - without intervention - with BF - with HAART
15-40% without intervention 15-29% from BF <2% with HAART
62
NNRTI class toxicities
rash | hepatotoxicity
63
IRIS DDx
``` relapse resistance drug toxicity new disease process - Rx dilemma: stop/continue ART, stop/change OI Rx, anti-infly agent, immunosuppressives ```
64
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 ```
65
Nodules / cavities on CXR
``` TB Fungus staph nocardia rhodococcus KS endocarditis ```
66
Clinical manifestiations of CD4 >200
``` 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 ```
67
Bicytopenia / pancytopenia in HIV | - causes
``` Malignancies - lymphoma, KS Infections - TB, MAC, VL, parvo B19, histo, cocci, crypto Aplastic anaemia, myelodysplasia Nutritional Drugs ```
68
CMV retinitis Rx
iv gangiclovir / PO valganciclovir if lesions not sight-threatening 2-3 wks follow with secondary prophylaxis
69
Normal CXR in HIV lung disease
PCP TB fungal bronchitis
70
benefits of boosting PIs with ritonavir
``` increased PI level b/c of less metabolism from cyt p450 inhibition fewer pills more predictable efficacy and activity lower toxicity less resistance ```
71
CNS mass lesion in HIV pts - causes
``` Common - toxo * - tuberculoma - lymphoma Less common - cryptococcoma - PML - bacterial abscess - other (syphilis, tumor, Chagas, Nocardia, Aspergillus) ```
72
Focal lesions on CXR
TB fungal bacterial nocardia
73
Meningitis in HIV pts - causes
``` cryptococcus TB syphilis bacterial - strep, listeria viral fungal lymphoma ```
74
5 min neuro screen: | pain in feet, decreased DTRs
sensory neuropathy ('d' drugs)
75
cells infected by HIV
CD4 T cells macrophages dendritic cells
76
5 min neuro screen: | cauda equina syndrome
CMV radiculitis
77
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
78
Diffuse infiltrates on CXR
``` PCP TB fungal KS CMV LIP ```
79
Rx cerebral toxo
pyrimithemine + sulfadiazine (+ folinic acid) | alt clind+pyrimeth, high dose TMP/SMX, dapsone, atovaquone
80
Nevirapine risk and RFs for it
``` hypersensitivity rxn (rash, hepatotoxicity) - esp men with CD4>400, women CD4>250 ```
81
Spectrum of HAND (HIV-associated neurocognitive disorder)
ANI - asympt neurocog impairment MND - minor neurocog disorder HAD - HIV-associated dementia
82
preferred TB PI
efavirenz
83
ICP elevation
crypto
84
PTx on CXR
PCP
85
problem with abacavir (ABC) and how to prevent
hypersensitivity rxn 3-7% - mortality | predict with HLA-B5701 test
86
most common cause of retinitis in AIDS
CMV
87
Acute HIV infection - time after
3-10 weeks
88
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 ```
89
NNRTI features
long half-life 2-3 wks lots of drug interxns not active vs HIV-2 or group O risk resistance
90
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 ```
91
risks of starting ARV at low CD4
higher risk OI higher risk toxicity non-AIDS related complications more common (CVD, Ca, liver, renal disease)
92
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
93
preferred PI in pregnancy
lopinavir/ritonavir
94
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 ```
95
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) ```
96
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) ```
97
Lactic acidosis Sx
``` A, N, V, AP pancreatitis, hepatitis SOB, arrhyth multi-organ failure, death = increased anion gap + lactate ```
98
Etiologies if small volume diarrhoea
colitis / proctocolitis - tenesmus, bld, mucus - shigella - campylobacter - C diff - HSV - CMV
99
Clinical manifestations of CD4 <100
``` can be asympt Fungal candida oesophagitis Cryptococcus Viral disseminated CMV Bact disseminated MAC Parasite toxo Microsporidiosis Chronic cryptosporidiosis Ca CNS lymphoma ```
100
ARVs to avoid in TB
PIs - interxn with rifampicin | NVP - use EFV instead (can use if needed)
101
Lactic acidosis RFs
``` female older age high BMI - esp d4T, ddI, combination + - esp 1st 3/12 Rx ```
102
Benefits of ART
``` prevent OI, Ca Alter/reverse course of existing OIs Improve/preserve immune ftn ↓ Sx ↑ QOL Restore hope ↓ transmission ```
103
Pleural effusion on CXR
``` TB bacterial KS lymphoma uraemia CHF hypoalbuminemia ```
104
Common lung disease aetiologies in HIV
TB PCP (pneumocystis jiroveci) bacterial fungal
105
AIDS definition
CD4<14% | AIDs defining illnesses (opportunistic infections)
106
Commonest cause of bacterial pneumonia in HIV
pneumococcus (100x increased risk)
107
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 ```
108
AIDS-defining cancers
Kaposi's sarcoma Primary CNS lymphoma NHL invasive Cx Ca
109
Etiologies if large volume diarrhoea
small bowel disease - cryptosporidium - microsporidium - cystoisospora - giardia
110
seizures, focal deficits
toxo
111
Potential reasons for non infectious complications of HIV
``` chronic immune system stimulation chronic inflammation premature aging mitochondrial damage (esp d drugs, NRTIs) drug toxicity ```
112
Thrombocytopenia in HIV - frequency | - causes
40% patients - may be early sign of HIV Periph destruction due to autoantibodies - HIV, drugs BM probs - infections, malignancy
113
Cancers with increased incidence in HIV (not dependent on CD4)
``` liver cancer Hodgkin's disease anal cancer melanoma oropharyngeal cancer lung cancer ```
114
Lactic acidosis management
- 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
115
Treatment failure WHO definition
Clinical - new/recurrent stage 4 condition (IRIS excluded) Immunological - fall of CD4 to baseline / 50% from peak Virological - VL >5000
116
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 ```
117
NRTI class toxicities
``` mitochondrial toxicity - neuropathy, LA lipodystrophy myopathy hepatitis pancreatitis hyperlipidaemia ```
118
Cause of Kaposi's sarcoma
Human herpesvirus 8
119
Dyslipidaemia in HIV - causes
HIV | ARVs - esp boosted PIs, also NRTIs, efavirenz
120
AIDS-associated cancers (not AIDS-defining)
primary effusion lymphoma | SCC conjunctiva
121
subacute progressive deficits
PML
122
Clinical manifestations of CD4 100-200
``` can be asympt Resp PCP Histoplasmosis / coccidiomycosis Military/extrapulm TB Cardiomyopathy Neuro neuropathies / myelopathy Dementia PML Other wasting NHL ```
123
Adenopathy on CXR
TB fungal MAC lymphoma
124
CMV retinitis lesions
2/3 unilateral 'cheese and ketchup' uveitis rare
125
5 min neuro screen: | strength ok but slow mentation
HIV dementia
126
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 ```
127
HIV important glycoproteins and their function
gp120 - binds CD4 receptor and co-receptor (CXCR4 or CCR5) | gp41 - promotes fusion of viral and cellular membranes
128
NRTIs active against hep B
lamivudine 3TC | tenofovir TDF
129
NRTI - least to most toxic (roughly)
``` Lamivudine 3TC Emtricitabine FTC Tenofovir TDF Abacavir ABC Zidovudine AZT Didanosine ddI Stavudine d4T ```
130
Rx crypto meningitis
ampho B + flucytosine / fluconazole 800mg | or flucyt+flucon 1200mg or flucon 1200mg
131
Risk of MTCT - without intervention - with BF - with HAART
15-40% without intervention 15-29% from BF <2% with HAART
132
NNRTI class toxicities
rash | hepatotoxicity
133
IRIS DDx
``` relapse resistance drug toxicity new disease process - Rx dilemma: stop/continue ART, stop/change OI Rx, anti-infly agent, immunosuppressives ```
134
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 ```
135
Nodules / cavities on CXR
``` TB Fungus staph nocardia rhodococcus KS endocarditis ```
136
Clinical manifestiations of CD4 >200
``` 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 ```
137
Bicytopenia / pancytopenia in HIV | - causes
``` Malignancies - lymphoma, KS Infections - TB, MAC, VL, parvo B19, histo, cocci, crypto Aplastic anaemia, myelodysplasia Nutritional Drugs ```
138
CMV retinitis Rx
iv gangiclovir / PO valganciclovir if lesions not sight-threatening 2-3 wks follow with secondary prophylaxis
139
Normal CXR in HIV lung disease
PCP TB fungal bronchitis
140
benefits of boosting PIs with ritonavir
``` increased PI level b/c of less metabolism from cyt p450 inhibition fewer pills more predictable efficacy and activity lower toxicity less resistance ```
141
WHO goals for PMTCT
Reduce MTCT to <2% (from 25%) in BF pop
142
2 key approaches of PMTCT
- lifetime ARV THERAPY for HIV infected women in need of Rx for her own health - ARV PROPHYLAXIS to prevent MTCT during preg, delivery and BF for HIV infected w not in need of Rx
143
Risk of vertical HIV transmission
Without intervention - 15-30% non- breast feeding - 20-45% breastfeeding
144
Lactic acidosis sx
Anorexia, N, V, AP Pancreatitis, hepatitis SOB, arrhythmia Multi-organ failure, death
145
Lactic acidosis RFs in ARV Rx
Female Older High BMI
146
Benefits of HIV therapy
``` Prevent OI &malignancies Improve existing OIs Decrease symptoms Improve health &QOL Restore hope Reduce HIV transmission ```
147
2 types of IRIS
- new dx | - paradoxical: worsening of previously known condition
148
iRIS
Immune reconstitution inflammatory syndrome

Tropical disease (24 decks)

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