Signs and Sxs of Pneumocystis Carinii Pneumonia
-- most common opportunistic infection assoc. with AIDS (very rarely does it occur outside of immunocompromised pts) -fever, cough, SOB (hypoxia: w/o PO2
Dx of PCP
- CXR: cornerstone of dx see diffuse or perihelia infiltrates -Wright-Giemsa stain or direct fluorescence AB (DNA) test on induced sputum - bronchoalveolar lavage - Elevated lactase dehydrogenase (LDH): occurs in 95% of cases
Risk of getting PCP?
Prophylaxis of PCP
- continued until CD4 count is above levels used to initiate tx - hx of infection: continue until they have had a durable virologic response to HAART for at least 3-6 months and maintain CD4 count >250
Complications of PCP
- increased incidence of pneumothorax, especially with hx of PCP and tx with aerosolized pentamidine
MAC (mycobacterium Avian complex) - what it is and dx
- R/O disseminated first if symptomatic - meningeal involvement is most common form of disseminated disease dx: blood cultures will be positive if disseminated
Signs and sxs of MAC
- spiking fevers - night sweats - diarrhea - wt loss - wasting - anemia and neutropenia - meningeal signs
Risk of MAC occurs?
- when CD4 is less than 50
Prophylaxis for MAC
- should be initiated with CD4
Kaposi's sarcoma background
- Moritz Kaposi: 1872 - 4 subtypes - classic K.S. - middle aged men of mediterranean descent - African endemic K.S. - in iatrogenically immunosupressed pts - AIDS related K.S.(most common form seen in U.S.)
What will lesions look like and where will they appear in K.S.
- may appear anywhere: most often on face and legs, palate, eyelids, conjunctiva, pinnae, toe webs - look purplish, will be NONBLANCHING, may be papular or nodular, appear more brown in dark skinned people, they are not painful
Kaposi's sarcoma -> visceral disease
- Dermatological Kaposi's isn't life threatening - but may progress to visceral disease in about 40% of patients with derm. K.S., thus becoming life-threatening.
Signs and Symptoms of KS of intestinal tract
- abdominal pain - diarrhea - intestinal obstruction
Signs of KS of lymph system
-swelling of arms or legs
KS of the Lungs
- cough, chest pain, SOB, difficulty breathing, extremity swelling, pulmonary blockage (alveoli or vascular system in lungs)
Can KS be tx?
- w/ contained skin lesions, tx may not be necessary. Lesions that involve large areas of skin or internal organs, tx is recommended. Tx include: topical meds, surgical removal, freezing with liquid nitrogen, chemo drugs
What has been proven to shrink KS lesions in advanced cases where it has affected internal organs? What adverse effects does this have?
- chemotherapy has proven effective - unpleasant SEs as N/V and hair loss - drugs can have damaging affects on the heart and bone marrow, resulting in decrease in number of white blood cells, furthering the risk of acquiring opportunistic infections
What are liposomal drugs?
Daunoxome (liposomal form of Daunorubicin) -> tx KS - these are similar to chemo drugs with one exception: they are encased in microscopic fat bubbles which seem to lessen adverse SEs - studies have shown that these forms of drugs last longer and are able to move to the KS affected areas better.
What is cryptococcus neoformans? signs and sxs?
- most common life-threatening fungal infection in AIDS -> meningitis - signs and sxs: meningitis/ subtle sxs: fever,, HA, malaise
Dx and Tx of cryptococcus neoformans
- latex agglutination serum/CSF testing for AG (CRAG) Tx: amphotericin B (Fungizone, Amphocin) prophylaxis: fluconazole (Diflucan)
- diarrheal disease caused by microscopic parasite Cryptosporidium - can live in the intestine of humans and animals and passed in the stool - Protected by an outer shell that protects it: allows it to survive outside of the body for extended periods, makes it very resistant to chlorine-based disinfectants - one of the most common causes of waterborne diseases in humans in the US - Parasite is found in every region of US and throughout the world. - ** Generally only affects immunocompromised pts
Sxs of Crypto
- most common: watery diarrhea -stomach cramps, dehydration, N/V, fever, wt loss - some pts asymptomatic - small intestine is most commonly infected - sxs begin 2-10 days following infection - non-immunocompromised sxs last 1-2 weeks - HIV pts w/ CD4 200: 2-4 weeks, however, may remain in carrier state and give to others or infect self if CD4 count drops
Pathogenesis of crypto parasites
- millions of crypto parasites are released in each BM from infected pts: transmission through fecal oral route, swimming or bathing in contaminated water, drinking contaminated water (most filtration systems don't filter crypto spores)
Dx of crypto
- stool specimens for cryptosporidium - specifically ask for the test (not done on routine O&P on stools) - Acid fast staining, direct fluorescent Ab (DFA), or enzyme immunoassays
Tx of crypto
- no approved tx for HIV+ pts, if CD-4 count can be improved, they may have remission but no cure
CMV signs and sxs
- most common retinal infection in AIDS pts - signs: perivascular hemorrhages sxs: usually a painless loss of vision, often unilateral, blurred vision, floaters
Tx of CMV retinitis
- ganciclovir (cytovene) given in 2 phases: induction and maintenance, due to high relapse rates - alt: foscarnet (Foscavir): less likely to cause neutropenia, but has many other possible AEs
GI manifestations in AIDS
- candidal esophagitis: very common in HIV pts, suggestive sxs are tx and only non-responsive pts are give endoscopy - Hepatic disease: autopsy shows that liver is very frequent site for disease/neoplasms, many of these are subclinical, co-infection with Hep B and C is common, low level hepatic disease may be cause for persistent N/V - Biliary Disease: acalculous cholecystitis with sclerosing cholangitis
Esophageal candidiasis Signs and sxs
- is an AIDS defining illness, as opposed to oral candidiasis. occurring in individuals with CD4 counts less than 100
Dx of esophageal candidiasis
- a presumptive dx can usually be made with a recent onset of dysphagia, especially in the presence of thrush, and empiric anti fungal therapy may be started - if pt fails to improve clinically after 3-7 days of therapy, an endoscopy should be performed for a definitive dx - endoscopy reveals: classiv diffuse raised plaques that characteristically can be removed from mucosa by the endoscope. - brushing or bx of the plaques show hyphae that are characteristic of Candida species.
Tx of esophageal candidiasis
- fluconazole 200 mg as initial dose, then 100 mg by mouth once daily for 14 days, IV therapy can be given to pt if pt is unable to swallow pills. - alt (less effective) txs include itraconazole capsules 200 mg once daily or ketoconazole 200 mg once daily for 14 days
Acute (Primary HIV) period: Window phase
- its the time between infection and detectable HIV abs (before 25 days)
Acute (primary HIV) period: Eclipse phase
- time between infection and detectable HIV RNA (0-10 days)
Acute (primary HIV) period: acute illness phase
- symptomatic disease: often precedes positive AB test (b/t day 15 and day 25), when HIV RNA peaks