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)
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
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
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
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
What is the baseline evalv of HIV?
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)
Monitor HIV via: CD4 counts, viral load every 3-6 months, more often if changing/starting ART
Regular chemistries, CBC to monitor side effects
When do we start ART?
What are the goals of ART? (4)
Right away. Treat all persons with HIV regardless of CD4
1. Improve survival
2. Improve QOL
3. Restore immune funciton
4. DEC HIV transmission
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)
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
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
What is the presentaiton of Pneumocystitis Pneumonia?
What are usually the CD4 counts we see this at?
What are some lab findings and symptoms?
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
What are other common lung disease of HIV? (8)
Bac pneumo (S. pneumo)
coccidioidomcosis (SW US)
Respiratory viruses (influenza)
tumors- lymphoma, Kaposi's sarcoma
DX: sputum/BAL, or biopsy
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
Treatment and prevention options for Toxo?
Sulfadiazine + pyrimethamine
Clindamycin + pyrimethamine
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)
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
CNS lymphoma in HIV:
nearly always due to?
What would be seen in an MRI?
Nearly always due to EBV reactivation
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
How does crypto manifest in a HIV pt?
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
Mycobacterium Avium presentation:
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
Bone biopsy and culture (faster)
Liver -- granulomas (less accessible)
Blood culture for AFB -- can take weeks/slow
Acid Fast stain +
Clarithromycin or azithromycin +
Rifabutin or ciprofloxacin or amikacin
Prophylaxis if CD4 <50
Azithromycin 1200mg weekly until CD4 >100 for 3 months
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
neoplasm caused by HHV 8
Abnormal angiongenesis --> purplish/brown lesions of skin, mucosa, viscera - edemetaous and painfun!
Can regres with ART, may need chemo
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
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