HIV - virus and clinical lecture Flashcards Preview

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Flashcards in HIV - virus and clinical lecture Deck (23):
1

Best test to diagnose for HIV?

 

 

HIV RNA PCR (can also detect prior to seroconversion), also used to follow response to ART

 

Current recommendation is to do a combined antibody/antigen assay, that detects p24 antigen + HIV antibodies (this will also detect an acute infection)

2

Acute/Primary HIV infection:

When is the onset after exposure?

 

What are the symptoms?

Onset 1-4 weeks after exposure

 

50-90% of people have at least some symptoms but htey are nonspecific- mimics EBV, CMV, syphilis, measles and other viral illnesses

Ie) fever, fatigue, pharyngitis, wt losos, myalgias, lymphadenopathy, thrombocytopenia, leukopenia, maculopapular rash, oral ulcers, H/A, diarrhea, N/V, aspectic meningitis

3

How do we characterize an acute/primary infection?

 

What is the significance?

High viral loads

below normal CD4 count (NL: 500-1200)

 

High risk of transmission -->need to recognize and dx to tyr to reduce secondary transmission

 

 

4

Who should we screen?

everyone 13-64 y/o as part of routine health care (req. to opt out rather than opt in)

 

People at high risk? ANNUALLY

Test those with STI, TB, illness compatible with HIV, pregnant

5

How do we know if treatment is effective?

Run a RNA PCR at baseline and periodically through treatment

 

viral load should become undetectable if effective ART

20-50 copies/mL

6

What is the baseline evalv of HIV?

 

Then what...

Complete history and exam

Screen for depression, immunization status, travel hx...

ROS directed at possible opportunistic complications

Labs...tons of them. 

STIs, infections, pap smear, Toxo, labs for med side effects and genotypes (ie -HLA B5701)

 

THEN:

Monitor HIV via: CD4 counts, viral load every 3-6 months, more often if changing/starting ART

Regular chemistries, CBC to monitor side effects

7

When do we start ART?


What are the goals of ART? (4)

Right away. Treat all persons with HIV regardless of CD4

 

Goals:

1. Improve survival

2. Improve QOL

3. Restore immune funciton 

4. DEC HIV transmission

8

What is still lacking in HIV treatment?

 

What are HIV positive individuals at higher risk for?

Doesn't fully restore health - gap in lifespan

ONLY 30% are virally suppressed, only 40% engage in care! -- lacking HIV care treatment to those who need it

 

INC risk of non-HIV complications: CVD, non-AIDS cancers, osteoporosis, renal dz, neurocognitive decline

 

HIV and its treatment may be risks for accelerated aging and organ damage, side effects of ART (DM, lipid/renal/CV disorders)

9

What are HIV+ individuals at risk during....

Primary HIV (5)

CD > 50 (3)

CD 200-500 (4)

CD <200 (8)

 

What are HIV+ ppl always at increased risk for?

Primary HIV: fever, pharyngitis, myalgias, adenopathy, rash

CD > 50: neuropathy, bell's palsy, thrombocytopenia

CD 200-500: Shingles, TB, bac pneumo, non-CNS lympoma

CD <200: Trush, PJP, Kaposi Sarcoma, Cyptococcus, MAC, CMV, PML, CNS lymphoma

 

What are HIV+ ppl always at increased risk for? Bell's palsy

Greater immuno suppression

10

What are some initial HIV manifestations that could point us to HIV?

Seborrheic dermatitis - superficial fungal infection at nasal/labio folds

Hairy Leukoplakia (EBV) - doesn't respond to therapy

 

Herpes Zoster (worry about eye with nasal invovlement

11

What is the presentaiton of Pneumocystitis Pneumonia?

 

What are usually the CD4 counts we see this at?

 

What are some lab findings and symptoms?

 

Dx

Tx

Prophylaxis??

Often insidious symptoms presents for weeks

Exam is normal, but pt can desaturate quickly with walking

ELEVATED LDH (nonspecific)

CXR - can be nl in 10-39% of the pt with PJP OR

bilateral reticulonodular interstitial infiltrates, perihilar CT more sensitive

 

RISK FACTORS: CD4 <200, oropharyngeal candidiasis or AIDS-defining illness

DX: sputum or BAL DFA/PCR or cytology

TX: TMP-SMX, clinda/primaquine, prednisone if significant hypoxia

Keep on TMP-SMX until CD >200 for more than 3 months

 

Alt: dapsone (if G6PD is normal) atovaquone, inhaled pentamidine

12

What are other common lung disease of HIV? (8)

Bac pneumo (S. pneumo)

TB

histoplasmosis

blastomycosis

coccidioidomcosis (SW US)

crytococcus

Respiratory viruses (influenza)

tumors- lymphoma, Kaposi's sarcoma

 

DX: sputum/BAL, or biopsy

13

Toxoplasmosis

What is it associated with?

When would we see it more often (CD4 counts?)

What would be typical manifestations of toxo?

How should a possible toxo case be managed?

Associated with undercooked meat with tissue cysts or ingesting cysts tha have been shed in cat feces

 

CD4 <100, esp <50

 

Typical manifestations: encephalitis with multiple brain lesions often ring-enhancing @ basal ganglia!

other symptoms may be non specific

 

Obtain baseline IgG

Positive? empiric Tx and assess response

If safe? LP with T. gondii PCR

If negative or lack of response to empiric tx - brain biopsy

14

Treatment and prevention options for Toxo?

Sulfadiazine + pyrimethamine

Clindamycin + pyrimethamine

TMP-SMX (bactrim)

 

PREVENTION: 

Bactrim daily until CD >200, for more than 3 months

Avoid raw/uncooked meath, shellfish

Avoid changing litter box, keep cats indoors, no raw meat

 

(same for pneumocystis)

15

What are some brain lesions that could be seen in HIV and their associated ilness (3):

toxo - ring enhancing

 

JC virus - progressive multifocal leukoencephalopathy (PML)

deep white matter lesions, no edema, no contrast enhancement, progressive cognitive, focal neurologic deficits, no brain sx like h/a

 

HIV encehalitis - large ventricles

lots of atropy, cognitive, behavior decline, dementia

16

CNS lymphoma in HIV:

 

nearly always due to?

CD4?

 

What would be seen in an MRI?

TX?

Nearly always due to EBV reactivation 

CD4 <100

 

MRI: often single lesion with contrast enhancement and edema/mass effect

sx: lethargy, h/a, focal neurologic signs, alt mentation

 

Tx: chemotherapy and radiation, ART

 

BAD PROGNOSIS, very advances, poor immune fxn

17

How does crypto manifest in a HIV pt?

 

DX?

TX?

Crypto:

fungus

CD4 <100

 

Sx: fever, h/a, alt mentation, pneumonia, skin lesions

DX: lumbar punction with opeming pressure, crypto antigen and fungal culture -- india ink/encapsulated yeast!!

 

Tx: amphotericin B + 5-flycytosine THEN fluconazole

maintain nl CSF pressure

18

Mycobacterium Avium presentation:

 

DX:

TX:

Most common cause of fever at low CD4 counts

(usually less than 50)

Non-specific sx- w/ central and not peripheral adenopath, hepatosplenomegaly, abd pain, pancytopenia, elv alk phos

 

DX:

Bone biopsy and culture (faster)

Liver -- granulomas (less accessible)

Blood culture for AFB -- can take weeks/slow

Acid Fast stain +

 

TX:

Clarithromycin or azithromycin +

Ethambutol +/-

Rifabutin or ciprofloxacin or amikacin

 

Prophylaxis if CD4 <50

Azithromycin 1200mg weekly until CD4 >100 for 3 months

19

Immune Reconstitution Inflammatory Syndrome (IRIS)

 

Occurs after ART initiation with INC in CD4 count

 

Systemic inflammatory syndome, with signs and symptoms identiacl to the infection -- NOT REALTED to uncontrolled infectio but rather to improved immune response from ART

 

Short term corticosteroids may be helpful

20

Kaposi Sarcoma

neoplasm caused by HHV 8

Abnormal angiongenesis --> purplish/brown lesions of skin, mucosa, viscera - edemetaous and painfun!

 

Can regres with ART, may need chemo

21

Bacillary Angiomatosis

caused by BARTONELLA HENSELAE and BARTONELLA QUINTANA, gram neg bacteria

 

associated with: cat expsoure, homlessness/lice

sx: fever, anorexia, wt loss

vascular lesions that involve skin, may look like KS

can infect nodes, bone, other organs

22

CMV retinitis

reactivation of latent infection

rentinal dz most common in HIV

usualy with CD4 <50

Floaters often an initial sx --> scrambled egg and ketup/pizza pie lesion

 

TX: gangciclovir

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