HIV + OI Flashcards
(309 cards)
1
Q
Through what TWO mechanism does HIV cause disease of the central nervous system (CNS)?
A
1) DIRECT impact from HIV
2) indirect due to CD4 DEPLETION
2
Q
Space occupying lesion + HIV - differential diagnosis - INFECTIVE causes?
A
Toxoplasmosis TB Cryptococcus Syphilitic gummae PML
3
Q
Space occupying lesion + HIV - differential diagnosis - NEOPLASTIC causes?
A
Primary CNS lymphoma
Metastatic non-Hodgkin lymphoma
4
Q
Encephalitis + HIV - differential diagnosis?
A
HIV (directly)
VZV
HSV
syphilis
5
Q
Meningitis + HIV - differential diagnosis?
A
HIV seroconversion Cryptococcus TB Syphilis Streptococcus pneumonia
6
Q
Spastic paraparesis + HIV - differential diagnosis?
A
HIV-vacuolar myelopathy Transverse myelitis HSV HTLV-1 Toxoplasmosis Syphilis
7
Q
Polyradiculitis + HIV - differential diagnosis?
A
CMV
Non-Hodgkin lymphoma
8
Q
What is the most common systemic FUNGAL infection associated with immunosuppression from HIV?
A
CRYPTOCOCCUS
9
Q
What type of organism is CRYPTOCOCCUS?
A
encapsulated YEAST
in environment
10
Q
What is the most common STRAIN of cryptococcus?
A
CRYPTOCOCCUS neoformans GRUBII
11
Q
In addition to grubii, which other strains of cryptococcus are common in HIV?
A
neoformans NEOFORMANS
or
neoformans GATTII
12
Q
What has CRYPTOCOCCUS neoformans GATTII been found in?
A
EUCALYPTUS trees
13
Q
What has CRYPTOCOCCUS neoformans NEOFORMANS been found in?
A
BIRD (Pigeon) droppings
14
Q
In what region is CRYPTOCOCCUS neoformans GATTII most common?
A
TROPICAL or SUBTROPICAL region
15
Q
How does CRYPTOCOCCUS enter the body?
A
INHALATION
rapidly spreads from LUNG to CNS
16
Q
What common dermatological manifestation in HIV does cryptococcal skin disease resemble?
A
MOLLUSCUM
17
Q
What is the most common symptoms of cryptococcus meningitis?
A
HEADACHE
FEVER
18
Q
In addition to cryptococcus meningitis what other systems may be affected by cryptococcus?
A
RESPIRATORY
SKIN papule/molluscum-like
BLOOD
19
Q
In cryptococcus disease what is the clinical presentation of haematological disease?
A
FEVER
NIGHT SWEATS
RIGORS
20
Q
Which system does CRYPTOCOCCUS most commonly affect?
A
CNS
21
Q
What is the most sensitive test for cryptococcus disease?
A
CSF for cryptococcal antigen
22
Q
What is a useful initial investigation for cryptococcus disease to guide further management?
A
serumccryptococcal antigen (CRAG) (if positive, do LP)
23
Q
If serum cryptococcal antigen (CRAG) is positive what investigation is indicated?
A
LP for CSF and manometry
24
Q
Prior to lumbar puncture for neurology associated with HIV and low CD4 what investigation should be performed?
A
CT or MRI of brain
25
What are poor prognostic indicators for cryptococcal disease?
```
Blood CULTURE positive
low white cell count on CSF
high CSF cryptococcal ANTIGEN
CONFUSED
raised intracranial PRESSURE
```
26
What is INDUCTION therapy for cryptococcal meningitis?
```
LIPOSOMAL AMPHOTERICIN B
4mg/kg/day
+
5-FLUCYTOSINE
100mg/kg/day
TWO (2) weeks
```
27
What is MAINTENANCE therapy for cryptococcal meningitis?
FLUCONAZOLE 400mg daily
| EIGHT (8) weeks
28
Is prophylaxis recommended for cryptococcal disease?
SECONDARY only
29
What is SECONDARY prophylaxis for cryptococcal meningitis?
FLUCONAZOLE 200mg daily
30
What is the BENEFIT of adding FLUCYTOSINE to induction treatment for cryptococcal disease?
quicker STERILISATION of CSF
31
What is the DISADVANTAGE of adding FLUCYTOSINE to induction treatment for cryptococcal disease?
haematological TOXICITY
32
What toxicity is amphotericin B associated with?
RENAL
33
Which preparation of amphotericin B is associated with less RENAL toxicity?
LIPOSOMAL
34
How is raised intracranial pressure managed in cryptococcal meningitis?
repeated lumbar puncture
| reduce pressure to <200mmH20 or 50% opening
35
If repeat lumbar puncture does not improve ICP in cryptococcal meningitis what is recommended?
NEUROSURGICAL input
| VP shunt
36
Cryptococcal meningitis + corticosteroid - is it useful?
NO
37
If cryptococcal disease is not involving CNS what is the treatment?
FLUCONAZOLE 400mg daily
then
secondary prophylaxis
38
When should ART be started following treatment for cryptococcal disease?
TWO weeks
39
What are common manifestations of cryptococcal IRIS?
```
aseptic meningitis
raised ICP
space occupying lesion
pulmonary infiltrates/cavities
lymphadenopathy
hypercalcaemia
```
40
When can SECONDARY prophylaxis for CRYPTOCOCCAL disease be STOPPED?
CD4 >100
&
undetectable VL 3 months
41
What is the most common cause of CNS mass lesions in immunocompromised people with HIV?
Toxoplasma abscess
42
What type of organism is TOXOPLASMA GONDII?
obligate intracellular protozoan
43
Which site of which animal is toxoplasma gondii reliant on to complete its life cycle?
Feline (CAT) INTESTINAL tract
44
How do humans acquire toxoplasma gondii?
Eating dead animal
or
ingesting oocytes from contaminated soil, water, food
45
What is the mechanism of TOXOPLASMOSIS disease in immunocompromised people?
REACTIVATION of infection acquired in early life
46
What is the risk of developing toxoplasma encephalitis if IgG T gondii positive and HIV positive, not on ART?
25%
47
What is the typical presentation of toxoplasma abscess?
FOCAL neurology
headache
vomiting
seizures
48
What is the preferred imaging modality for toxoplasma abscess?
MRI
49
In addition to brain imaging, what other investigation is useful to help diagnose toxoplasma abscess?
LP for CSF PCR for T gondii
50
What is the main differential diagnosis for toxoplasma abscess?
Primary CNS Lymphoma
Tuberculoma
PML
51
What is the typical and appearance of toxoplasma abscess on brain imaging?
MULTIPLE
RING enhancing
Grey-White interface
DEEP GREY matter of basal ganglia or thalamus
52
What patient factor may result in a lack of ring enhancement of toxoplasma abscess?
Low CD4 cell count
53
What features of a CNS mass suggest LYMPHOMA more likely than toxoplasma abscess?
SINGLE
| Periventricular
54
What features of a CNS mass suggest PML more likely than toxoplasma abscess?
WHITE matter
rarely enhancing
no mass effect
55
What imaging modality is useful to help distinguish between lymphoma and toxoplasma abscess?
SPECT - high uptake in lymphoma
56
What is first line treatment for toxoplasma encephalitis/abscess?
```
PYRIMETHAMINE
loading 200mg then 50-75mg/day
+
FOLINIC acid 15mg/day
+
SULPHADIAZINE
1-2gram 4x/day
```
57
If a person cannot tolerate SULPHADIAZINE for toxoplasma abscess, what is the alternative?
CLINDAMYCIN
| 600mg 4x/day
58
Why is folinic acid given as part of treatment for toxoplasma abscess?
to counteract MYELOSUPPRESSIVE effect of PYRIMETHAMINE
59
How long is induction therapy for toxoplasma abscess?
SIX (6) weeks
60
What is the MAINTENANCE regimen for toxoplasma abscess?
```
same drugs as induction, LOWER dose
PYRIMETHAMINE
25mg/day
+
FOLINIC acid 15mg/day
+
SULPHADIAZINE
500mg 4x/day or 1-2gram 2x/day
```
61
When are steroids indicated for toxoplasma encephalitis?
symptoms or signs of raised intracranial pressure
62
What is the dosing regimen for steroids in the event of raised intracranial pressure due to toxoplasma abscess?
DEXAMETHASONE 4mg 4x/day
| wean gradually
63
Within what time frame is a response to antimicrobials expected when treating toxoplasma abscess?
TWO weeks
64
When should brain biopsy be considered in the context of treatment for toxoplasma abscess?
No response to treatment at 2 weeks
or
clinical deterioration on treatment
65
When do PLW HIV need PRIMARY prophylaxis for toxoplasmosis?
CD4 cell count <200
66
What is the first line primary PROPHYLAXIS for toxoplasma abscess?
Co-trimoxazole
| 480-960mg daily
67
How long should PROPHYLAXIS for toxoplasma abscess be continued?
until CD4 >200
&
on ART THREE (3) months
68
How long should MAINTENANCE for toxoplasma abscess/encephalitis be continued?
until CD4 >200
&
on ART SIX (6) months
69
When should ART be started in the context of toxoplasma abscess?
2 weeks after toxoplasma treatment started
70
What organism causes progressive multifocal leukoencephalopathy (PML)?
Virus JC
71
What proportion of the population are seropositive for JC virus?
70%
72
Where does JC virus remain latent in immunocompetent people?
spleen
bone marrow
kidneys
Blymphocytes
73
What happens to JC virus in IMMUNOSUPPRESSED people?
```
REPLICATES
transported to BRAIN
by B-LYMPHOCYTES
infects OLIGODENDROCYTES
via SEROTONIN receptor
```
74
What proportion of people with AIDS develop PML from JC virus?
5%
75
What is the pathological process of PML?
IRREVERSIBLE
| DEMYELINATION
76
What is the typical presentation of PML?
SUBACUTE
PROGRESSIVE
FOCAL neurology
77
What investigations are required to make a diagnosis of PML?
MRI brain
| CSF for JC PCR
78
What are the poor prognostic factors in PML?
```
OLDER age
BRAINSTEM involvement
LOW GCS
HIGH JC viral load in CSF
CD4 <100
```
79
What is the treatment for PML?
ART
80
What is the one year survival for PML on ART?
50%
81
What is the one year survival for PML not on ART?
10%
82
What type of virus is cytomegalovirus (CMV)?
Human B-Herpes virus (type 5)
83
Which population group at risk of HIV is most likely to be seropositive for CMV?
MSM (nearly all)
84
Through what mechanism is does CMV develop in PLW HIV?
REACTIVATION leads to
VIRAEMIA
+
END-ORGAN disease
85
At what CD4 count does risk of end organ disease from CMV increase?
<50
86
Which is the main site of CMV disease?
RETINA (3/4 of CMV disease)
87
Other than the retina, what other sites can have CMV disease?
```
GI tract
LUNG
LIVER
HEART
ADRENAL
CNS
```
88
What proportion of CMV disease affects the RETINA?
3/4
89
What proportion of CMV disease affects the CNS?
<1%
90
What is the typical presentation of CMV ENCEPHALITIS?
```
progressive DISORIENTATION
WITHDRAWAL
APATHY
Cranial nerve PALSY
NYSTAGMUS
```
91
What is the typical presentation of CMV lumbosacral POLYRADICULITIS?
```
PAINFUL
rapidly PROGRESSIVE
BILATERAL
ASCENDING flaccid paralysis
saddle anaesthesia, areflexia, spincter dysfunction, urinary retention
```
92
What are the investigations for CMV CNS disease?
MRI brain
+
LP for CMV PCR on CSF
93
What are the CT findings in CMV encephalitis?
diffuse WHITE matter hypodensities
ventricular ENLARGEMENT
MENINGEAL enhancement
Ring-enhancing
94
What is the finding in CSF in CMV CNS disease?
polymorphonuclear cell PLEOCYTOSIS (wcc)
95
Which antivirals have efficacy against CMV retinitis?
GANCICLOVIR
FOSCARNET
valganciclovir
cidofovir
96
What is the preferred FIRST line treatment for CMV CNS disease?
```
Ganciclovir 5mg/kg
TWICE daily
THREE (3) weeks
then
maintenance
```
97
Is prophylaxis required for CMV CNS disease?
No
98
What is the maintenance therapy for CMV CNS disease?
IV Ganciclovir 5mg/kg DAILY
or
oral VALGANCICLOVIR 900mg daily
99
What are causes of NON-INFECTIOUS HIV-related lung disease?
```
KS
Lymphoma
Lung CANCER
EMPHYSEMA
Lymphoid interstitial pneumonitis (LIP)
Non-specific interstitial pneumonitis (NSIP)
IRIS
SARCOID
Pulmonary hypertension
Pulmonary thromboembolic disease
```
100
What type of organism is pneumocystis jirovecii?
FUNGUS
101
What proportion of PCP occurs in PLW HIV with CD4 count <200?
90%
102
What is the typical presentation of PCP?
EXERTIONAL dyspnoea
PROGRESSES over weeks
MALAISE
dry COUGH
103
What should presentation of pneumothorax in a PLW HIV prompt investigation for?
PCP
104
What proportion of PCP have a normal CXR?
40%
105
What observation is useful to perform in suspected PCP with a normal CXR?
oxygen saturation on exercise
106
Through what TWO processes should respiratory sample be got for investigation of PCP?
INDUCED sputum
or
Broncho-alveolar lavage (BAL)
107
What is more specific, direct visualisation or NAAT for pneumocystis jirovecii?
direct visualisation
108
For how long can adequate respiratory samples be obtained for investigating PCP after starting treatment?
7-10 days (ie don't delay Rx)
109
PCP - moderate/severe disease (for treatment purposes) - define?
PaO2 <9.3kPa (70mmHg)
or
SpO2 <92%
110
What is the FIRST line treatment of moderate/severe PCP?
IV co-trimoxazole
+
CORTICOSTEROIDS
TWENTY ONE (21 ) days
111
What is the dose of CO-TRIMOXAZOLE for moderate/severe PCP?
```
IV co-trimoxazole
120mg/kg/day (split 3x or 4x daily)
THREE (3) days
then
90mg/kg/day
EIGHTEEN (18) days
```
112
Why is there a dose reduction of co-trimoxazole for PCP treatment?
Similar efficacy
less toxicity
than continuous high dose
113
What is the CORTICOSTEROID regimen for moderate/severe PCP?
```
PREDNISOLONE
40mg TWICE daily days 1-5
40mg ONCE daily days 6-10
20mg ONCE daily days 11-21
then stop
```
114
What is the appropriate conversion to methylprednisolone for PCP treatment if oral route is not available?
75% of oral regimen
| 30 BD/30 OD/15 OD
115
How long may treatment for PCP take to show improvement?
7 days or more
116
What are suitable alternative agents for treatment of PCP?
Clindamycin
Primaquine
Pentamidine
117
What is the definition of MILD PCP disease - presentation, O2, CXR?
- SOB on exertion +/- cough/sweats
- PaO2 >11kPa (83mmHg), SaO2 >96
- normal CXR
118
What is the definition of MODERATE PCP disease - presentation, O2, CXR?
- SOB on minimal exertion, cough + fever
- PaO2 8.1-11kPa (61-83), SaO2 91-96
- Diffuse interstitial changes
119
What is the definition of SEVERE PCP disease - presentation, O2, CXR?
- SOB at rest
- PaO2 <8.0kPa (<60), SaO2 <91
- Extensive interstitial changes
120
G6PD deficiency should be checked prior to which drugs used for PCP treatment?
Co-trimoxazole
Dapsone
Primaquine
121
Which groups of people are most likely to have G6PD deficiency?
African
Mediterranean
Sephardic Jews
Chinese
122
What is the risk in a person with G6PD?
Haemolysis with certain drugs
123
What non-invasive ventilation is useful for hypoxia related to PCP?
CPAP
124
At what CD4 count is PCP prophylaxis recommended in PLW HIV?
CD4 <200
or
<14%
125
What is the preferred regimen for PCP prophylaxis?
480mg daily
(less side effects)
can use 960mg daily or 960mg 3x/week)
126
What cross protection does co-trimoxazole offer in terms of OI prophylaxis in PLW HIV?
PCP
toxoplasmosis
other bacterial infection
127
Other than co-trimoxazole which agents provide cross protection for both PCP + toxoplasmosis?
Dapsone + pyrimethamine
or
Atovaquone
128
When should ART be started following PCP treatment start?
within 2 weeks
129
When can PCP prophylaxis stop?
CD4 >200
+
3 months on ART
130
In what situation may PCP prophylaxis be required lifelong?
PCP infection at CD4 count>200
131
Which organisms are most likely cause of bacterial pneumonia in PLW HIV?
Streptococcus pneumoniae
| Haemophilus influenzae
132
What is the association between bacteraemia and pneumonia in PLW HIV?
higher rates bacteraemia in PLW HIV compared to HIV negative people
133
What investigation is indicated in for work up for pneumonia in PLW HIV?
```
Sputum culture (if purulent)
CXR
Blood culture (if inpatient)
```
134
What preventative measure can be used to reduce risk of bacterial pneumonia in PLW HIV?
Polysaccharide vaccine 23 (PCV-23)
| - protects against 23 serotypes of pneumococcus
135
What is the treatment regimens for community acquired pneumonia in PLW HIV - mild, moderate, severe disease?
same as HIV negative
- amoxicillin oral
- amoxicillin + macrolide or doxycycline
- IV co-amoxiclav + macrolide
136
How does pulmonary CRYPTOCOCCOSIS present?
similar to PCP
| SOB, fever, cough
137
What feature on CXR may be present in pulmonary CRYPTOCOCCOSIS?
solitary nodules
| cavities
138
If pulmonary CRYPTOCOCCOSIS is suspected what additional investigation is required other than respiratory sample?
CSF for CNS disease
&
serum CRAG is helpful
139
If pulmonary CRYPTOCOCCOSIS is present in isolation what is the treatment?
Fluconazole 400mg DAILY
TEN (10) weeks
then
200mg daily
140
What fungus commonly colonises the lung of people with lung disease?
Aspergillus
141
When does invasive aspergillosis occur?
Aspergillus INVADES parenchyma
| DISSEMINATION to other organs
142
What factors increase the risk of invasive aspergillosis in PLW HIV?
```
RARE
but
NEUTROPENIA
TRANSPLANTATION
STEROID use
```
143
What investigations are required to diagnose aspergillosis in PLW HIV?
Fungal culture of sample
CT chest
Broncho-alveolar lavage (BAL)
Bronchoscopy +/- biopsy
144
What does the galactomannan test check for in aspergillosis?
detects presence of a cell wall constituent of aspergillus
145
What is the FIRST line regimen for invasive ASPERGILLOSIS?
```
Loading:
VORICONAZOLE
6mg/kg TWICE daily
24 hours
then
4mg/kg TWICE daily
SEVEN (7) days
then
200mg TWICE daily
TWELVE (12) weeks total
```
146
What is required to improve absorption of voriconazole?
Take with FULL meal
147
Is prophylaxis required in PLW HIV for pulmonary aspergillosis?
NO
| Maintenance may be required in chronic aspergillosis syndromes
148
What does the detection of CMV in urine,l blood or BAL without evidence of end organ disease mean?
CMV INFECTION
| but not DISEASE
149
How is PULMONARY CMV diagnosed?
BAL or respiratory biopsy CMV positive
+
Clinical syndrome
150
What is the limitation of respiratory sampling in diagnosing pulmonary CMV?
CMV commonly sheds in respiratory tract but does not mean end-organ disease
151
When should anti-CMV treatment be given in the setting of respiratory disease?
NO alternative diagnosis
+
CMV in BAL or biopsy
152
If it is likely they is co-infection with CMV and another pathogen causing respiratory disease, what is the management?
Treat co-pathogen first
153
What is the treatment for pulmonary CMV?
Ganciclovir 5mg/kg
TWICE daily
21 days
154
What is the association between PLW HIV and Influenza A virus?
more SEVERE disease
155
What is the investigation of choice for influenza A?
nasal swab for viral swab
156
What treatment option can be considered for PLW HIV and influenza A?
OSELTAMIVIR
157
When is oseltamivir indicated for influenza A treatment?
Fever
<48 hours
or significant immunosuppression
158
What is the regimen for OSELTAMIVIR to treat influenza A?
Oseltamivir
75mg TWICE daily
5 days
159
What is the potential benefit of ZANAMIVIR for the treatment of Influenza A in PLW HIV?
improved EFFICACY in those with significant IMMUNOSUPPRESSION due to oseltamivir RESISTANCE
160
In addition to treatment for influenza A. what else should people with immunocompromise be treated with?
antibiotics
| DOXCYCLINE or CO-AMOXICLAV
161
What 3 specific criteria might should be met to consider influenza A prophylaxis?
1) CD4 <200
2) not vaccinated against flu
3) exposure < 48 hours
162
Why is primary or secondary prophylaxis not recommended for oesophageal candidiasis?
rapid emergence of RESISTANCE
163
In what specific situation might continuous treatment with FLUCONAZOLE be recommended for people with recurrent oesophageal candidiasis?
4 or more episodes per year
| continuous = less resistance
164
What investigations are indicated in acute diarrhoea in PLW HIV?
Stool culture
+
Blood culture (especially if sepsis)
165
How often is retinal screening recommended in PLW HIV and CD4 count <50?
3 monthly
166
How is diagnosis of CMV retinitis made?
on visualisation of retina
+/-
symptoms
167
Is oral or IV therapy preferred in CMV retinitis?
ORAL
| valganciclovir
168
What is the preferred regimen for CMV retinitis?
```
VALGANCICLOVIR oral
900mg TWICE daily
TWO weeks
then
maintenance
```
169
When is ganciclovir implant or intravitreal injection recommended for CMV retinitis?
Lesions affecting zone 1 ie near OPTIC DISC
or
unable to tolerate systemic therapy
170
What needs to be monitored whilst on anti--CMV treatment?
```
RENAL function
ELECTROLYTES
BONE MARROW (ie FBC)
```
171
When can anti-CMV treatment be stopped?
```
CD4 >100
and
undetectable VL
+
agreement with ophthalmologist
```
172
Why might anti-CMV treatment fail?
DOSE related
or
RESISTANCE
173
If a woman of reproductive age is treated with CIDOFOVIR for CMV what should she be advised?
No pregnancy ONE month
174
If a man of reproductive potential/desire is treated with CIDOFOVIR for CMV what should he be advised?
No conception THREE month
175
What group of PLW HIV are at greatest risk of immune recovery uveitis in CMV retinal disease?
25% of retina affected
176
If a PLW HIV has CMV IRIS what is the recommendation for eye follow up?
LIFELONG
177
In addition to antiviral treatment of CMV what is recommended for CMV IRIS?
STEROIDs
178
What other pathogens may cause eye disease in PLW HIV?
SYPHILIS
TOXOPLASMOSIS
VZV
179
How may syphilis present in the eye?
```
IRITIS
VITRITIS
OPTIC NEURITIS
PAPILLITIS
NEURORETINITIS
RETINAL VASCULITIS
NECROTISING RETINITIS
```
180
How should ocular syphilis be treated?
the same as NEUROSYPHILIS
181
What is the most common cause of POSTERIOR UVEITIS in immunoCOMPETENT people?
TOXOPLASMOSIS
182
What TWO aggressive eye syndromes are associated with VARICELLA ZOSTER virus?
PROGRESSIVE outer retinal necrosis (PORN)
&
ACUTE retinal necrosis (ARN)
183
Why is visual prognosis poor in patients with VZV associated retinal necrosis?
risk of:
retinal DETACHMENT
ISCHAEMIC optic neuropathy
OPTIC NERVE involvement
184
What is the treatment of choice for VZV eye disease in PLW HIV?
CIDOFOVIR
185
Pyrexia of unknown origin - define?
```
FEVER >38.3
several occasions
>FOUR weeks
or
> 3 days in hospital, after negative initial investigation
```
186
What is the overall most common cause of PUO in PLW HIV?
INFECTION
187
Why is a LIFETIME travel history essential in PUO in PLW HIV?
REACTIVATION of tropical infection frequent
188
In PLW HIV on ART what are the common causes of PUO?
LYMPHOMA
| TB
189
What other broad causes should be considered in PUO in PLW HIV?
```
Non-infective:
RHEUMATOLOGICAL
CONNECTIVE TISSUE disease
VASCULITIS including temporal arteritis
Polymyalgia rheumatica
SARCOID
```
190
On starting ART what might PUO be a sign of?
IRIS to underlying pathogen
191
BARTONELLOSIS (Bartnella sp.) can be a cause of PUO in PLW HIV - how is this diagnosed?
Culture and PCR of BLOOD or BIOPSY
192
How is bartonellosis treated?
ERYTHROMYCIN
500mg 4x/day
THREE months
193
What cutaneous manifestation is bartonellosis associated with in PLW HIV?
BACILLARY ANGIOMATOSIS
194
What is BACILLARY ANGIOMATOSIS?
```
FRIABLE
red
vascular
EXOPHYTIC lesions
papules or nodules
```
195
What initial blood tests are recommended in PLW HIV and PUO?
```
FBC
U&E, LFT
CRP
LDH
serum CRAG
Blood cultures
SYPHILIS serology
HEPATITIS serology
CMV serology
```
196
When are ANA and rheumatoid factor recommended in the investigation of PUO in PLW HIV?
if CONNECTIVE tissue disease suspected
197
What initial imaging is recommended in PLW HIV and PUO?
CXR
| Echo
198
Culture of what sample is recommended in PLW HIV and PUO?
URINE
SPUTUM inc for Mycobacterium
BLOOD
199
What additional system specific investigation is recommended in PLW HIV and PUO and CARDIO-RESPIRATORY symptoms?
ECHO
VTE screen
Bronchoscopy +/- BAL
200
What additional system specific investigation is recommended in PLW HIV and PUO and GASTROINTESTINAL symptoms?
```
STOOL culture for culture, OVA, CYSTS, PARASITES
ENDOSCOPY - upper &/or lower GI
+/- BIOPSY
US abdomen
+/- CT abdomen
```
201
What additional system specific investigation is recommended in PLW HIV and PUO and NEUROLOGICAL symptoms?
```
CRAG
CT brain with CONTRAST
+/- MRI brain
CSF
EEG
```
202
What additional system specific investigation is recommended in PLW HIV and PUO and MUCOCUTANEOUS symptoms?
BIOPSY
Drug review
STI screen
203
What additional system specific investigation is recommended in PLW HIV and PUO and LYMPHADENOPATHY?
FNA
excision biopsy
CT chest/abdomen/pelvis
204
What additional system specific investigation is recommended in PLW HIV and PUO with ABNORMAL LFTS?
```
HEPATITIS serology
CMV PCR
US liver +/- CT
Toxicology
BIOPSY
PARASITE serology
```
205
When is bone marrow aspirate indicated in PLW HIV and PUO?
When a diagnosis for PUO has not been made through other investigation or haematological malignancy or disseminated infection likely (ie TB/leishmaniasis)
206
What are the THREE phases of herpes viruses infection?
PRIMARY
LATENT
REACTIVATION
207
What are the THREE broad groups within the herpes virus family?
ALPHA (HSV 1,2 and VZV)
BETA (CMV, HHV6 & 7)
GAMMA (EBV & HHV8)
208
What virus causes varicella infection (chickenpox) and zoster (shingles)?
VARICELLA ZOSTER virus
209
How is VZV acquired?
Through respiratory route
210
Which site of the body does VZV establish latency?
DORSAL ROOT GANGLIA
211
What is the impact of immunosuppression on VZV latency?
REACTIVATION more likely
more SEVERE disease
DISSEMINATED more likely
212
If PRIMARY VZV occurs in PLW HIV what is the potential clinical sequelae?
DISSEMINATED disease
| PNEUMONITIS
213
What is the risk of VZV reactivation on starting ART?
2-4 fold increase risk of disease in first few months due to IRIS
214
What is the definition of HERPES ZOSTER OPHTHALMICUS?
VZV disease involves the ophthalmic division of trigeminal nerve
215
What are the potential complications of herpes zoster ophthalmicus?
```
Loss of vision
Keratitis
anterior uveitis
severe neuralgia
necrotising retinopathy
```
216
What CNS complications can occur from VZV infection in PLW HIV?
```
leukoencephalitis
vasculitis with infarct
myelitis
meningitis
optic neuritis
```
217
What is the recommended treatment for VZV varicella infection?
IV ACICLOVIR 10mg/kg 3x/day
| 7-10 days
218
What is the recommended treatment for VZV zoster infection?
oral ACICLOVIR 800mg 5x/day
| 7 days
219
Which site of the body does herpes simplex virus establish latency?
LOCAL SENSORY GANGLIA
220
Which HSV is more common in PLW HIV than HIV negative people?
HSV2
221
What is the risk of HIV transmission in a person with genital HSV2 compared to no HSV?
2x higher
222
Which sites of the body may be affected by systemic HSV disease?
```
EYE
LUNG
LIVER
OESOPHAGUS
CNS
```
223
What is the definitive investigation for HSV encephalitis?
CSF for HSV DNA PCR
224
What is the treatment for oral or genital HSV in PLW HIV?
oral ACICLOVIR
400mg 5x/day
7-10 days
225
What agent can be used in aciclovir resistant HSV?
FOSCARNET
226
What is the most common non-TB mycobacterium that causes infection in PLW HIV?
Mycobacterium avium
227
In which group of PLW HIV does disseminated mycobacterium avian occur?
CD4 <50
228
What are common symptoms or signs of MAI?
```
Fever
Night sweats
Fatigue
Weight loss
Anorexia
Diarrhoea
Hepatomegaly
Lymphadenopathy
```
229
What are common blood abnormalities of MAI?
Anaemia
Leukopenia
raised ALP
low albumin
230
What a unusual clinical syndromes may be suggestive of MAI?
Oral ulceration
Septic arthritis/osteomyelitis
Enophthalmitis
Pericarditis
231
What is the definitive investigation for MAI?
Culture of blood, bone marrow or sterile site (ie not sputum or stool)
232
What is the preferred regimen for MAI?
```
macrolide:
CLARITHROMYCIN 500mg TWICE daily
or
AZITHROMYCIN 500mg daily
+
ETHAMBUTOL 15mg/kg/DAY
+/-
RIFABUTIN 300mg/DAY
```
233
When should RIFABUTIN be added to treatment for MAI?
High risk of short term MORTALITY
- CD4 <25
- very symptomatic of MAI
- inability for ART
234
What is the benefit of adding RIFABUTIN to treatment regimen for MAI?
- improved SURVIVAL
| - less RESISTANCE
235
When should ART be started in the context of MAI?
Immediately or within 2 weeks of MAI Rx
236
What is the criteria to STOP treatment for MAI in PLW HIV?
```
THREE months treatment
+
VL undetectable
+
CD4 >100 for 3 MONTHS
```
237
In the event that an alternative treatment regimen is required for MAI, what is the benefit of continuing ETHAMBUTOL?
facilitates PENETRATION of other agents into MYCOBACTERIUM
238
In the event of focal MAI (ie pulmonary disease) what is the recommended length of treatment?
12 months
| 3 drug regimen
239
In which instances should PRIMARY prophylaxis for MAI be considered?
```
CD4 <50
+
not on ART
or
ART failure
```
240
If PRIMARY prophylaxis for MAI is given what is the recommended regimen?
AZITHROMYCIN 1250mg WEEKLY
241
What useful ADJUNCTS to usual therapy may be considered in MAI IRIS?
- PREDNISOLONE 20-40mg 4-8 weeks
- IL-2 or GCSF
- Leukotriene inhibitors
- Fine needle aspiration of pus due to lymphadenitis
242
What is the SECOND most common non-TB mycobacterium that causes infection in PLW HIV?
Mycobacterium kansasii
243
What is the recommended regimen for M. kansasii?
```
RIFAMPICIN/RIFABUTIN
+
ETHAMBUTOL
+
ISONIAZID + PYRIDOXINE
```
for TWELVE (12) months
244
For how long should the recommended regimen for M. kansasii be given?
12 months
245
What is the most common presentation fo Mycobacterium KANSASII?
PULMONARY
246
What type of organism is malaria?
protozoal parasite
247
How is malaria transmitted?
BITE by FEMALE ANOPHELES mosquito
248
What is the most serious malaria species?
plasmodium FALCIPARUM
249
What is the association between CD4 count and severity of malaria?
CD4 <200 more likely SEVERE malaria
250
What is the clinical presentation of MALARIA?
```
FEVER
HEADACHE
ARTHRALGIA
MYALGIA
DIARRHOEA
```
251
What are the potential complications of malaria?
```
HYPERPARASITAEMIA
AKI
DIC
HYPGLYCAEMIA
LACTIC ACIDOSIS
FULMINANT HEPATIC FAILURE
CEREBRAL MALARIA
```
252
Within what time frame does plasmodium FALCIPARUM present?
THREE (3) months
253
How is MALARIA diagnosed?
THICK and THIN blood film
254
What does the THICK blood film look for in MALARIA?
diagnose malaria
| percentage of parasitaemia
255
What does the THIN blood film look for in MALARIA?
speciation
256
If a blood film is NEGATIVE but MALARIA is suspected, what other test can be done?
RAPID antigen test
257
What is the definition of SEVERE FALCIPARUM malaria?
>2% parasitaemia
+/-
organ dysfunction
258
What is the treatment for SEVERE FALCIPARUM?
IV artesunate
259
What is the treatment for non-severe FALCIPARUM?
ORAL artemether-lumefantrine
260
What is the potential CARDIAC complication of IV quinine?
prolonged QRS and QT interval
261
What is the treatment for NON-FALCIPARUM malaria?
oral CHLOROQUINE THREE days
then
oral PRIMAQUINE FOURTEEN days
262
Which agent used in treatment of non-falciparum malaria can cause haemolysis in people with G6PD deficiency?
PRIMAQUINE
263
Why are there TWO phases to treatment for non-falciparum malaria?
2nd phase to ERADICATE liver parasite stages
264
What does the ABCD of malaria PREVENTION stand for?
Awareness of risk
BIte prevention
Chemoprophylaxis
Diagnosis and treatment
265
What are the main options for MALARIA PROPHYLAXIS?
MALARONE
DOXYCYCLINE
CHLOROQUINE + PROGUANIL
266
What type of organism is leishmania?
Protozoa
267
How are leishmania sp. transmitted?
SANDFLY
268
What are the THREE types of leishmania disease?
VISCERAL
MUCOCUTANEOUS
CUTANEOUS
269
What is the most common type of LEISHMANIA in PLW HIV?
VISCERAL
270
What organomegaly is most likely in visceral leishmaniasis?
SPLENOMEGALY
271
How does a cutaneous leishmania lesion present?
PAPULE to a chronic, DESTRUCTIVE ulcer
272
What are the preferred specimens for diagnosis of visceral leishmaniasis?
SPLENIC
BONE MARROW
BIOPSY of lymph node or skin lesion
273
What is the treatment regimen for VISCERAL leishmaniasis?
Liposomal AMPHOTERICIN B
4mg/kg 10 doses, 6 week course
day 1-5, 10, 17, 24, 31, 38
274
What is the relapse rate of treated leishmaniasis in PLW HIV?
HIGH
275
What prophylaxis is recommended for leishmaniasis in PLW HIV?
SECONDARY only (pre-ART)
276
When can SECONDARY prophylaxis be stopped in visceral leishmania?
CD4 >200 for 3-6 months
| on ART
277
What is the organism that causes CHAGAS disease?
PARASITE
| TRYPAHNOSOMA CRUZI
278
Where in the world is TRYPANOSOMA CRUZI limited to?
CENTRAL & SOUTH AMERICA
279
How is TRYPANOSOMA CRUZI transmitted to humans?
BITE of TRIATOMINE insect
280
What is the impact of immunosuppression on trypanosome cruzi?
REACTIVATION of infection
281
What are the TWO main presentations of trypanosoma CRUZI in PLW HIV?
```
CNS:
Space occupying lesion
Meningoencephalitis
CARDIAC:
Myocarditis
```
282
How is CHAGAS (trypanosoma cruzi) disease diagnosed?
Brain imaging
CSF for PCR
Biopsy
283
What is the treatment for HAGAS (trpanosoma cruzi) disease?
BENZNIDAZOLE
5mg/kg split TWO doses
60-90 days
284
Which DIMORPHIC fungi are of importance in PLW HIV?
HISTOPLASMA CAPSULATUM
BLASTOMYCES DERMATITIDIS
COCCIDIOIDES IMMITIS
PENICILLIUM MARNEFFEI
285
How does DISSEMINATED disease of DIMORPHIC FUNGI present in PLW HIV?
```
Fever
weight loss
rash
lymphadenopathy
lung consolidation or cavitation
CNS features
Sepsis
```
286
How is DISSEMINATED disease of DIMORPHIC FUNGI diagnosed in PLW HIV?
```
CULTURE of
sputum or BAL
Bone marrow
or
BIOPSY
```
287
What is the treatment summary for DIMORPHIC FUNGI in PLW HIV?
```
ITRACONAZOLE
histoplasma & blastomyces
FLUCONAZOLE
coccidioidomycosis
AMPHOTERICIN B
penicilliosis
```
288
What disease is caused by PENICILLIUM MARNEFFEI?
PENICILLIOSIS
289
What type of organism is PENICILLIUM MARNEFFEI?
DIMORPHIC FUNGI
290
What type of organism is HISTOPLASMA CAPSULATUM?
DIMORPHIC FUNGI
291
What type of organism is BLASTOMYCES DERMATITIDIS?
DIMORPHIC FUNGI
292
What type of organism is COCCIDIOIDES IMMITIS?
DIMORPHIC FUNGI
293
Which area of the World doesPENICILLIUM MARNEFFEI come from ?
Southeast Asia
294
Is PRIMARY prophylaxis recommended for PENICILLIOSIS in PLW HIV?
consider
CD4 <100
travel to endemic area
295
What is the regimen for PRIMARY prophylaxis of PENICILLIOSIS in PLW HIV?
ITRACONAZOLE 200mg daily
296
In pregnancy, what are the recommendations for CXR?
little or no risk to foetus
with
ABDOMINAL shield
297
In pregnancy, when can MRI be performed?
avoid FIRST trimester
298
In pregnancy, what parts of the body can be CT scanned?
BRAIN
CHEST
LIMBS
299
Why is it relatively safe to perform CT in pregnancy (not abdominal)?
little radiation scatter
300
In pregnancy, Can contrast for CT be used?
YES
301
Which opportunistic infections can be transmitted vertically?
```
TB
CRYPTOCOCCAL
CMV
PCP
TOXOPLASMOSIS
```
302
In pregnancy, treatment for PCP?
CO-TRIMOXAZOLE
| same as non-pregnant
303
In pregnancy, treatment for CRYPTOCOCCUS?
liposomal AMPHOTERICIN B
| same as non-pregnant
304
In pregnancy, treatment for CANDIDIASIS?
```
VAGINAL - topical preparation
ORAL - NYSTATIN
OESOPHAGEAL
- first trimester AMPHOTERICIN
- 2nd and 3rd trimerst - FLUCONAZOLE
```
305
In pregnancy, treatment for TOXOPLASMOSIS?
```
SULPHADIAZINE
+
PYRIMETHAMINE
+
FOLINIC ACID
```
306
In pregnancy, treatment for CMV?
GANCICLOVIR or VALGANCICLOVIR
| however all associated with congenital abnormality in animal studies
307
In pregnancy, what is the potential impact from active TB on birth outcomes?
Low birth weight
preterm birth
intra-uterine growth restriction
308
In pregnancy, treatment for TB?
```
RIFAMPICIN
+
ISONIAZID (with pyridoxine)
+
PYRAZINAMIDE
+
ETHAMBUTOL
ie RIPE
same as non-pregnant
```
309
pregnancy, treatment for MAI?
AZITHROMYCIN
