Opportunistic Infections in HIV

Question 1

what is IRIS

Answer 1

immune reconstitution inflammatory syndrome- exaggerated reaction to a pathogen when the immune system begins to recover on ARTs

Question 2

IRIS may ________ or ___________

Answer 2

unmask an undiagnosed infection
worsen a previously tx infection

Question 3

what type of fungi are OIs

Answer 3

yeasts- candida + cryptococcosis

Question 4

name 2 OIs

Answer 4

bacterial respiratory disease, cryptococcosis, cytomegalovirus (CMV), candidiasis, mycobacterium avium complex (MAC), mycobacterium tuberculosis (TB), pneumocystis pneumonia (PJP), toxoplasma gondii (Toxo)

Question 5

when should you start prophylaxing for PCP

Answer 5

CD4<200

Question 6

when should you start prophylaxing for toxo

Answer 6

CD4 <100

Question 7

when should you start prophylaxing for MAC

Answer 7

Cd4<50

Question 8

what is the best protection against OIs

Answer 8

ART

Question 9

what is a normal CD4 count

Answer 9

500-1500

Question 10

which of the following is false about PJP
1. it is transmitted by inhalation of ascospores
2. disease may occur if latent infection is reactivated
3. has a slower onset- worsens over days-weeks
4. 2/3s of healthy children have antibodies by age 2-4
5. sx, blood tests, and CXR may confirm dx

Answer 10

5- needs histopathologic/ cytopathologic demonstration of organisms in tissue
- either by BAL or induced sputum samples

Question 11

describe the clinical presentation of PJP

Answer 11

Progressive dyspnea, fever, nonproductive cough, chest discomfort

Subacute onset: worsens over days-wks (sudden onset possible but not common)

Chest x ray: diffuse, bilateral, symmetrical “ground glass” interstitial infiltrates, butterfly pattern

Question 12

which OI has symmetrical “ground glass” interstitial infiltrates

Answer 12

PJP

Question 13

what is the pref tx for PJP

Answer 13

TMP-SMX F 21 d + adj steroids

Question 14

what safety parameters need to be monitored for PJP tx with TMP-SMX

Answer 14

ARs high compared to pts without HIV (20-85%)- rash (30-55%), SJS, fever, leukopenia, thrombocytopenia, hepatitis, hyperkalemia
Renal dosing

Question 15

when is used for primary prophylaxis for PJP

Answer 15

TMP-SMA SS 1 tab daily or DS 1 tab daily or 3x/wk

Question 16

when should secondary prophylaxis for PJP start

Answer 16

ASAP after completion of PJP tx- same as primary prophylaxis = TMP-SMX

Question 17

when should primary and secondary prophylaxis for PJP be stopped

Answer 17

when pt is on ART and experiences immune recovery with CD4 >200 for 3 months

Question 18

toxoplasmic encephalitis is caused by
1. yeast
2. protozoan
3. mold
4. bacteria
5. virus

Answer 18

2

Question 19

TE occurs due to ____________

Answer 19

reactivation of latent tissue cysts

Question 20

primary infection of TE happens after ______ or ________

Answer 20

eating undercooked meat or oocytes shed in cat feces

Question 21

which of the following is true regarding TE
1. it is contagious
2. all pts should be tested for TE IgM antibody to TE immediately after HIV dx
3. may cause focal encephalitis and nonfocal sx
4. diagnosis is IgM antibodies + CT or MRI

Answer 21

3 is true
1- not transmitted person to person
2- IgG antibody used, not IgM
4- IgG antibodies + CT or MRI

Question 22

primary prophylaxis for TE should be started if

Answer 22

IgG + and CD4<100

Question 23

when should primary prophylaxis for TE be stopped (2)

Answer 23

when CD4 >200 for 3 months or
CD4 100-200 + HIV RNA undetectable for 3-6mths

Question 24

what is primary prophylaxis for TE

Answer 24

TMP-SMX

Question 25

what is used for TE tx

Answer 25

pryimethamine, sulfadiazine, leucovorin

Question 26

what is maintenance tx or secondary tx for TE

Answer 26

pyrimethamine, sulfadiazine, leucovorin

Question 27

when should secondary tx for TE be started

Answer 27

immediately after acute tx

Question 28

when should secondary prophylaxis for TE be stopped

Answer 28

when CD4 >200 for 6 months

Question 29

select all that apply to MAC 1. it is caused by a slow growing bacteria 2. is transmitted through inhalation or ingestion 3. 20-40% of people with HIV and advanced immunosuppression in ART error have it 4. onset is rapid and lethal 5. diagnosis requires isolation of MAC in blood cultures 6. colonization anywhere in the body is indicative of disease

Answer 29

1, 2, 5 3- for people not on ART 4- onset is slow 6- colonization of resp and GIT is not indicative of disease

Question 30

list 3 sx of MAC

Answer 30

Disseminated, multi-organ infection (localized may be seen) Fever, night sweats, weight loss, fatigue, diarrhea Localized manifestations (sx vary by site)

Question 31

how long should cultures be watched for MAC?

Answer 31

4-6wks- v slow growing

Question 32

when is primary prophylaxis for MAC recommended? 1. if the pt is HIV +, on ART, CD4 <50 2. if the pt is HIV +, not on ART, MAC blood culture negative 3. if the pt is HIV +, not on ART, CD4 <50 4. if the pt is HIV +, on ART, MAC blood culture negative 5. 1+3 6. 2+3

Answer 32

6

Question 33

what is the pref primary prophylaxis for MAC

Answer 33

azithro or clarithro

Question 34

what is tx and maintenance tx for MAC

Answer 34

clarithro or azithro

Question 35

when can secondary prophylaxis for MAC stop (3) - at least _____ months after tx - no _________ - CD4 _____ for ______

Answer 35

at least 12mths after tx no s/sx of MAC CD4 >100 for >6mths