ID - HIV

Question 1

Life expectancy of HIV +ve patient compared to -ve

Answer 1

8 years less (71 vs 79)

Question 2

Which HIV patients should you treat with ART?

Answer 2

all

Question 3

naming convention of HIV drugs

Answer 3

all integrase inhibitors end in: -gravir

Question 4

Favoured combination of HIV drugs (class wise)

Answer 4

Integrase inhibitor + 2 NRTI

OR

Integrase inhibitor + 1 NRTI

Question 5

If patient presents with new HIV and opportunistic infection what should you do re HIV meds

Answer 5

Start the HIV meds

2 caveats for delaying treatment:
- TB affecting the brain
- cryptococcal meningitis

(concerns regarding immune over-activation, inflammation and brain herniation)

Question 6

Tenofovir forms and link

Answer 6

TAF - Tenofovir alafenamide
Prodrug of TDF converted to TDF intracellular
TDF - Tenofovir Disoproxil fumarate

Question 7

AE Tenofovir (TDF)

Answer 7

renal disease, bone disease (more with TDF)
- less with TAF

Question 8

Pharmacokinetic relation of tenofovir forms (TAF vs TDF)

Answer 8

Tenofovir alafenamide (TAF) Prodrug of TDF converted to TDF intracellular

Question 9

Answer 9

TMP-SMX + pred

(Don’t treat CMV in HIV patients unless histological changes suggesting it’s pathogenic)

Question 10

HIV drugs contra-indicated in pregnancy

Answer 10

all are fine

Question 11

Abacavir AE

Answer 11

Hypersensitivity reaction ( 5-8%) if HLAB5701

Question 12

zidovudine AE

Answer 12

anaemia, Lipodystrophy

Question 13

Cardinal AIDS Defining Illnesses

Answer 13

• Kaposi Sarcoma
• CMV retinitis
• Disseminated Mycobacterium avium complex/Tuberculosis
• Pneumocystis pneumonia
• Oesophageal Candidiasis
• Toxoplasma encephalitis
• Chronic cryptosporidiosis / microsporidiosis

Question 14

CD4 count that HIV patients tend to get opportunistic infections

Answer 14

typically < 200

Question 15

Vaccine and HIV

Answer 15

don’t give live vaccines if CD4 < 200

Question 16

Primary prophylaxis in HIV

Answer 16

Question 17

HIV chest infections

Answer 17

Pneumococcus (S. Pneumonia)

Pneumocystis (PJP fungus)

TB (re-activation)

Question 18

Answer 18

PJP

Question 19

main symptom PJP pneumonia

Answer 19

SOBE

Question 20

Treatment for PJP pneumonia

Answer 20

trim-sulfa
- needs to make its own folate

Does not have ergosterol in it’s cell membrane therefore other antifungals (azoles/ampho) not effective

Steroids - If PaO2 < 70

Question 21

Diagnosis of PJP pneumonia

Answer 21

BAL PCR

Question 22

Indications of PJP prophylaxis (other than HIV with CD4 < 200)

Answer 22

• Prednisone > 20 mg /day for > 4 weeks
• ALL Induction to end of Maintenance
• Allo-HSCT – Engraftment > 6 mos after transplant provide off immunosuppression and no GVHD
• Alemtuzumab, Rituximab, anti-thymocyte - > 6 months after completion
• Solid organ transplant > 6 months (?lifelong for lung/intestinal txplant)

Question 23

Sx of cryptococcal meningitis

Answer 23

• Presents as subacute meningitis (25% do not have any meningeal signs (serum crypto ag+)
• Due toљ ICH – CN palsies, seizures (cryptococcoma)– but typically confusion and fevers

Question 24

LP finding crytococcal meningitis

Answer 24

• Opening pressure elevated in 60-80% - very high
• Lymphocytic, low glucose (but only in 40%), elevated protein
• CSF –Crypto Ag 94% positive, Culture 100% - PCR ~80%

Question 25

mgmt crytococcal meningitis

Answer 25

2 anti-fungal drugs until sterile LP (amphotericin + flucytosine) then conslidaiton - fluconazole 8 weeks Maintenance - 12 months lower dose fluconazole Control ICH - daily LP until < 25cm H2) Hold off on ARV for a little while - Typically start 4-6 weeks, CSF sterile

Question 26

HIV CNS toxoplasmosis presentation

Answer 26

* Most common cause of brain abscess – usually CD4 < 100, *<50 * If higher CD4 = need to think TB, lymphoma * Common presentation – headache, fever, seizures, AMS, focal deficits * Dx – must have Toxo IgG + serum – PCR of CSF for Toxo * Imaging – ring enhancing lesions – multiple – single can be confused Lymphoma

Question 27

Transmission of toxoplasmosis

Answer 27

* Feline feces (cats, lions) * Oocysts begin to be excreted 20 days post-infection * Rare meat (Lamb>Beef>Pork)

Question 28

HIV CNS toxoplasmosis treatment

Answer 28

* TMP-SMX * Adjuvant dexamethasone, if develop SZ - antiepileptic Teaching point – treat empirically for toxoplasmosis if ring enhancing lesions – if not better 2 weeks consult NS for brain biopsy

Question 29

IRIS

Answer 29

immune reconstitution inflammatory syndrome * results from restored immunity to specific infectious or non-infectious antigens. * A paradoxical clinical worsening of a known condition or the appearance of a new condition after initiating therapy characterizes the syndrome. * Many disease entities associated with IRIS – OI’s Sarcoidosis, Grave’s, * Timing – Usually w/i 6 weeks after ARV

Question 30

predicters of IRIS in HIV infection

Answer 30

high VL, low CD4 or high pathogen burden

Question 31

Most common IRIS opportunistic infections

Answer 31

* Mtb, MAI (Mycobacterium avium and intracellulare) * Cryptococcus * CMV

Question 32

IRIS treatment

Answer 32

* Continue ARV * Steroids – pred 40 -80 mg for 2-8 wks+, NSAID * Must exclude other entities AND no failure or your treatment of OI

Question 33

MAI infection

Answer 33

Mycobacterium avium-intracellulare infection * Decreasing incidence (hence why MAI prophylaxis dropped if starting ARVs) * Bx, blood cultures

Question 34

predicters of IRIS in HIV infection

Answer 34

high VL, low CD4 or high pathogen burden

Question 35

Appearnce of CMV retinitis

Answer 35

Ketchup on eggs

Question 36

Ix for CMV retinitis

Answer 36

* Fundoscopic exam * Rarely vitreal tap done CMV viral load not that helpful (correlates with CD4 count)

Question 37

Treatment of CMV retinitis

Answer 37

Immediate sight- threatening lesion * ARV * IV ganciclovir * Intravitreal ganciclovir Small peripheral lesion * ARV * Oral valganciclovir Typically expect improvement in 10-14 days