opportunistic infection: prevention and management

Question 1

Initiation of ART is effective treatment for OIs for which effective therapy does not exist

Answer 1

yep

Question 2

Starting ART in the setting of acute OIs is complicated by toxicity, drug-drug interactions and IRIS

Answer 2

yep yep

Question 3

A group of clinical syndromes associated with immune reconstitution observed most commonly for mycobacterial infections (TB, MAC), as well as with PJP, Toxo, CMV, cryptococcal infection

Answer 3

IRIS: Immune Reconstitution Inflammatory Syndrome

Question 4

IRIS usually presents within ________ after starting ART, in patients with high viral loads and low CD4+ counts. Inflammation takes weeks to months to subside
Early initiation of _____near the time of initiating OI treatment should be considered for most patients

Answer 4

IRIS usually presents within first 4–8 weeks after starting ART, in patients with high viral loads and low CD4+ counts. Inflammation takes weeks to months to subside
Early initiation of ART near the time of initiating OI treatment should be considered for most patients

Question 5

Indicator of immune suppression; most often seen with declining CD4 counts

Answer 5

candida albicans

Question 6

Before widespread use of ART and prophylaxis, 80% of patients developed____

Answer 6

PJP

Question 7

PJP

Answer 7

Progressive dyspnea on exertion, non-productive cough, developing over days to weeks

Question 8

in PJP we see something elevated… what is it?

Answer 8

Elevated 1,3ß-D-glucan level

***Beta D glucan is part of cell wall of PJP cysts

Question 9

Classic appearance on CXR: bilateral hilar interstitial infiltrates “butterfly pattern,” but many will have a clear CXR and can show pathchy ground glass opacities

Answer 9

PJP

Question 10

PJP diagnosis

Answer 10

Induced sputum is method of choice

but BAL or transbronchial biopsy: high diagnostic yield but more invasive

Question 11

PJP treatment

Answer 11

all treatment for 21 days

Bactrim(PO) and polus prednisone if a-a gradient >35/ acutely ill

Question 12

Many patients with PJP will get worse before they get better

Answer 12

yep, Radiologic appearance lags behind clinical deterioration or improvement

Question 13

Prophylaxis can be stopped if CD4 consistently >_____and plasma viral loads are undetectable in response to HAART

Answer 13

100-200

Question 14

PJP prophylaxis if

Answer 14

CD4 <200, thrush or AIDS defining illness

Question 15

Cryptococcal Meningitis caused by a

Answer 15

fungal organism

Question 16

what do we use to identify cryptococcal meningitis in CSF

Answer 16

india ink

Question 17

Gold standard treatment for cryptococcal meningitis

Answer 17

IV antifungal

Question 18

with cryptococcal meningitis treatment ____ will have IRIS; manage symptoms with steroids if needed

Answer 18

30%- Optimal time to start ART is not clear

Question 19

Mycobacterium Avium Intracellulare Complexc is a ______ growing mycobacterium. Acquired by _________; no person to person transmission. Infection with MAC is due to recent acquisition rather than reactivation; no latent phase

Answer 19

Mycobacterium Avium Intracellulare Complexc is a slow growing mycobacterium. Acquired by inhalation or ingestion; no person to person transmission. Infection with MAC is due to recent acquisition rather than reactivation; no latent phase

Question 20

MAC lab findings

Answer 20

anemia, elevated Alk. Phos and elevated LDH

Question 21

With MAC infection, IRIS typically presents as (2)

Can be self-limiting or can be severe and unremitting, requiring NSAIDS or steroids

Answer 21

With MAC infection, IRIS typically presents as lymphadenitis, granulomatous hepatitis
Can be self-limiting or can be severe and unremitting, requiring NSAIDS or steroids

Question 22

MAC diagnosis

Answer 22

lymph node biopsy

Question 23

treatment for MAC

Answer 23

macrolides

**All treatment should continue for at least one year

Question 24

MAC prophylaxis

Answer 24

CD4 <50; stopped when CD4 >100

Question 25

patients with CD4 counts <100 who are Toxoplasma IgG positive have a 30% probability of _______________________

Answer 25

developing reactivated toxo, if not on effective prophylaxis

Question 26

T. gondii most commonly reactivates in ____ leading to cerebral abscess

Answer 26

CNS

Question 27

diagnosis of toxo.

Answer 27

Toxoplasma seropositive (IgG positive) Gold standard is brain biopsy

Question 28

treatment of toxo.

Answer 28

Combination treatment (sulfadiazine and pyrimethamine/leucovorin; other options as well) for 6-8 wks, followed by suppression

Question 29

CMV Most commonly causes reactivation disease in HIV+ patients with CD4

Answer 29

CMV Most commonly causes reactivation disease in HIV+ patients with CD4 <50. Can involve almost every organ system, but 80% of infections are manifested as retinitis in HIV+ patients

Question 30

CMV with retinitis treatment (2)

Answer 30

1. intraocular antiviral injection | 2. ganciclovir

Question 31

CMV in the Gi tract Usually presents with _____. Can involve any part of the GI tract from the mouth to the anus. Often more persistent and focal than candidal esophagitis

Answer 31

CMV in the Gi tract Usually presents with fever. Can involve any part of the GI tract from the mouth to the anus.often more persistent and focal than candidal esophagitis

Question 32

treatment given when acute infection is under control but when CD4 count is still depressed

Answer 32

2° prophylaxis –

Question 33

treatment given prior to any signs of infection when CD4 < a particular value

Answer 33

1° prophylaxis –