SH Revision 4

Question 1

As a general rule, HIV regimens consist of [+]

What is the BHIVA recommendation drug regimens to start for HIV tx? [4]

Answer 1

As a general rule, regimens consist of:

Two nucleoside reverse transcriptase inhibitors (NRTIs)

A third agent, typically one of:
- Ritonavir-boosted protease inhibitor (PI/r)
- Non-nucleoside reverse transcriptase inhibitor (NNRTI)
- Integrase inhibitor (INI) - RECOMENDED

OR
- Dolutegravir + Lamivudine

This is the list of BHIVA preffered drug regimens to start

In theory; any of above can be used; but BHIVA slide is the.

Question 2

Name examples for NRTIs [4] and NNRTIs [2]

Answer 2

NRTIs:
* Tenofovir disoproxil fumarate
* Abacavir
* Emtricitabine
* Lamivudine

NNRTIs:
- Efavirenz
- Nevirapine

As NRTIs are the backbone - don’t want to be LATE with starting treatment Lamivudine, Abacavir TDF Emtricitabine

Question 3

Describe the MoA of PIs [1]

Answer 3

Protease inhibitors (PIs) inhibit the action of protease preventing the cleavage of Gag-Pol polyproteins.

Question 4

PIs are given alongside which drug [1] as they boost the action of the drug

Name two examples of PIs

Answer 4

They are given alongside ritonavir - referred to as a boosted PI - which increase the action of the drug.

PIs:
* Atazanavir
* Darunavir
* Lopinavir

Question 5

[] tend to have a high barrier to resistance and therefore may be preferred in patients where there are concerns regarding adherence

NRTIs
NNRTIS
PIs
II
EI

Answer 5

[] tend to have a high barrier to resistance and therefore may be preferred in patients where there are concerns regarding adherence

NRTIs
NNRTIS
PIs
II
EI

Question 6

Post-attachment inhibitors prevent envelope protein [] engaging with co-receptors.

Name an example [1]

Answer 6

Post-attachment inhibitors prevent envelope protein glycoprotein-120 engaging with co-receptors.

There is currently one medication in this class, the monoclonal antibody Ibalizumab. It is given as an IV infusion once every two weeks.

Question 7

Which drugs are contained in PEP? [2]
For how long is the course? [1]

Answer 7

Once a day of:
* Tenofovir disoproxil fumerate
* Two Raltegravir

for 28 days

Question 8

State 3 side effects of protease inhibitors [3]

Answer 8

There are many adverse effects including lipodystrophy, hyperlipidaemia, insulin resistance and hepatotoxicity.

Question 9

Which drugs are used in PrEP? [1]

Answer 9

Tenofovir-df/emtricitabine

Question 10

How do you measure safety and toxicity of ARTs? [3]

Answer 10

• Renal and liver test
• Lipids and metabolic tests
• FBCs

Question 11

Which ART might cause this reaction

Abacavir
Efavirenz
Tenofovir
Darunavir
Nevirapine

Answer 11

Which ART might cause this reaction

Abacavir - get HLAB5701 screen

Efavirenz
Tenofovir
Darunavir
Nevirapine

Question 12

Which two drugs make up long-acting drugs for HIV treatment? [2]

Answer 12

II and NNRTI

Question 13

Name two side effects of Tenofovir DF long term use [2]

Answer 13

Tenofovir DF:
- Tubular toxicity (prevents re-ab of certain solutes at PCT - risk of kidney failure
- Reduction in bone mineral density

Question 14

Name a side effect of abacavir long term use [1]

Answer 14

Dyslipidaemia / atherosclerosis

Avoid in ptx with high risk CVD

Question 15

Dolutegravir is which drug class? [1]

Answer 15

Integrase inhibitor

Question 16

Which drug class is associated with Cushingoid appearances? [1]

Answer 16

AZT / old medications

Question 17

Which drug is most likely to cause vivid dreams, and somnolence

Efavirenz
Emtricitabine
Lopinavir
Abacavir
Enfuvirtide (T-20)
Tenofovir
Atazanavir
Raltegravir
Ritonavir
Dolutegravir
Nevirapine

Answer 17

Which drug is most likely to cause vivid dreams, and somnolence

Efavirenz
Emtricitabine
Lopinavir
Abacavir
Enfuvirtide (T-20)
Tenofovir
Atazanavir
Raltegravir
Ritonavir
Dolutegravir

Question 18

Which drug is most likely to cause diarrhoea, nausea
Hyperlipidaemia

Efavirenz
Emtricitabine
Lopinavir
Abacavir
Enfuvirtide (T-20)
Tenofovir
Atazanavir
Raltegravir
Ritonavir
Dolutegravir
Nevirapine

Answer 18

Which drug is most likely to cause diarrhoea, nausea
Hyperlipidaemia

Lopinavir (PI)

Question 19

Which ART causes a risk of hypersensitivty? [1]

Which drug class does it belong to? [1]

Answer 19

Abacavir: hypersensitivity
- NRTI

Question 20

Renal disease is caused by long term use of which ART? [1]

Answer 20

Tenofovir

Question 21

Which ART causes a risk of hepatotoxicity? [1]

Which drug class does it belong to? [1]

Answer 21

Nevirapine NNRTI

Question 22

Which ART can cause this reaction? [1]

Which drug class? [1]

Answer 22

Darunavir
- PI

NB: Reaction = SJS

Question 23

Efavirenz can cause which side effects? [3]

Answer 23

Neuropsychotic / CNS side effects:
- impaired concentration
- mood swings
- sleep disturbance

Question 24

Which drug is most likely to cause elevation in bilirubin (unconjugated)

Efavirenz
Emtricitabine
Lopinavir
Abacavir
Enfuvirtide (T-20)
Tenofovir
Atazanavir
Raltegravir
Ritonavir
Dolutegravir
Nevirapine

Answer 24

Which drug is most likely to cause elevation in bilirubin (unconjugated)

Atazanavir (PI)

Question 25

Which drug is most likely to cause **a severe reaction at the injection site** Efavirenz Emtricitabine Lopinavir Abacavir Enfuvirtide (T-20) Tenofovir Atazanavir Raltegravir Ritonavir Dolutegravir Nevirapine

Answer 25

Which drug is most likely to cause **a severe reaction at the injection site** Efavirenz Emtricitabine Lopinavir Abacavir **Enfuvirtide (T-20)** Tenofovir Atazanavir Raltegravir Ritonavir Dolutegravir

Question 26

Which drug is most likely to cause **mood / sleep disturbance and is an II?** Efavirenz Emtricitabine Lopinavir Abacavir Enfuvirtide (T-20) Tenofovir Atazanavir Raltegravir Ritonavir Dolutegravir Nevirapine

Answer 26

Which drug is most likely to cause **mood / sleep disturbance and is an II?* **Dolutegravir**

Question 27

Which drug is most likely to cause **SJS** Efavirenz Emtricitabine Lopinavir Abacavir Enfuvirtide (T-20) Tenofovir Atazanavir Raltegravir Ritonavir Dolutegravir Nevirapine

Answer 27

Which drug is most likely to cause **SJS** **Nevirapine**

Question 28

Which drug is most likely to cause **renal dysfunction** Efavirenz Emtricitabine Lopinavir Abacavir Enfuvirtide (T-20) Tenofovir Atazanavir Raltegravir Ritonavir Dolutegravir Nevirapine

Answer 28

**Tenofovir**

Question 29

Which drug is most likely to cause **reduced bone minderal density** Efavirenz Emtricitabine Lopinavir Abacavir Enfuvirtide (T-20) Tenofovir Atazanavir Raltegravir Ritonavir Dolutegravir Nevirapine

Answer 29

**tenofovir**

Question 30

Which drug is most likely to cause **an increased risk of CVD** Efavirenz Emtricitabine Lopinavir Abacavir Enfuvirtide (T-20) Tenofovir Atazanavir Raltegravir Ritonavir Dolutegravir Nevirapine

Answer 30

Which drug is most likely to cause **an increased risk of CVD** Efavirenz Emtricitabine Lopinavir **Abacavir** Enfuvirtide (T-20) Tenofovir Atazanavir Raltegravir Ritonavir Dolutegravir Nevirapine

Question 31

Which antiretroviral is most likely to be responsible for jaundice? Abacavir Atazanavir Darunavir Efavirenz Emtricitabine/FTC Lamivudine/3TC Lopinavir Nevirapine Raltegravir Ritonavir Tenofovir | TMS

Answer 31

**Atazanavir**

Question 32

Generalised itchy rash with raised liver enzymes 2-4 weeks into treatment is most likely? [1]

Answer 32

**Nevirapine**

Question 33

Risk of weight gain seems to be higher with some ART agents: - Tenofovir **[]** is associated with more weight gain than Tenofovir **[]**, which may be protective

Answer 33

Risk of weight gain seems to be higher with some ART agents: - **Tenofovir alafenamide (TAF)** is associated with more weight gain than **Tenofovir (TDF)**, which may be protective ## Footnote TAF --> FAT

Question 34

**[Drug class]** are associated with more weight gain than other ART: Raltegravir >

Answer 34

**Integrase Inhibitors** are associated with more weight gain than other ART: Raltegravir >

Question 35

**[]** tend to exacerbate the cytopenic effects of chemotherapy. NNTRIS NRTIs IIs PIs FI

Answer 35

**NRTIs** tend to exacerbate the cytopenic effects of chemotherapy.

Question 36

**[]** are potent liver enzyme inducers and may lower the levels of other drugs NNTRIS NRTIs IIs PIs FI

Answer 36

**[]** are potent liver enzyme inducers and may lower the levels of other drugs **NNTRIS** NRTIs IIs PIs FI

Question 37

How should you manage infants born to HIV infected mothers? [1]

Answer 37

**Most infants should be given AZT monotherapy for 4 weeks**

Question 38

When should an elective caesarean section should be planned for 38 weeks? [2]

Answer 38

Women on combination therapy with detectable viraemia Women with HIV / HCV co-infection

Question 39

For ART to be successful, adherence rates must be in the range of **[]-[]**%

Answer 39

For ART to be successful, adherence rates must be in the range of **90-95%**

Question 40

35 yo man, CD4 count 500, right sided chest pleuritic chest pain and temperature of 38.5 degrees. What is the most likely causative organisms? Adenovirus Aspergillus fumigatus Cryptococcus neoformans Cytomegalovirus Haemophilus influenzae Histoplasma capsulatum Mycobacterium avium cellulare Mycobacterium TB Pneumocystis jiroveci Pseudomonas aeruginosa Staphylococcus aureus Streptococcus pneumonia

Answer 40

**Streptococcus pneumoniae** - This is because his CD4 is normal, so we immediately can cross out every cause of disease in low CD4

Question 41

35 yo man, CD4 of 100, SOB on exertion and a temperature of 38 Adenovirus Aspergillus fumigatus Cryptococcus neoformans Cytomegalovirus Haemophilus influenzae Histoplasma capsulatum Mycobacterium avium cellulare Mycobacterium TB Pneumocystis jiroveci Pseudomonas aeruginosa Staphylococcus aureus Streptococcus pneumonia

Answer 41

200 – cut-off for CD4 count when we start worrying about **opportunistic infections** Answer: **pneumocystis jiroveci** – most common opportunistic respiratory infection in ppl with low CD4 count

Question 42

**35 yo lady from Zimbabwe, CD4 of 300, temperature of 37.8** Adenovirus Aspergillus fumigatus Cryptococcus neoformans Cytomegalovirus Haemophilus influenzae Histoplasma capsulatum Mycobacterium avium cellulare Mycobacterium TB Pneumocystis jiroveci Pseudomonas aeruginosa Staphylococcus aureus Streptococcus pneumonia

Answer 42

**Zimbabwe** – high prevalence of TB & HIV (they overlap & are synergistic)

Question 43

**35 yo pigeon fancier, CD4 of 50, temperature 38** Adenovirus Aspergillus fumigatus Cryptococcus neoformans Cytomegalovirus Haemophilus influenzae Histoplasma capsulatum Mycobacterium avium cellulare Mycobacterium TB Pneumocystis jiroveci Pseudomonas aeruginosa Staphylococcus aureus Streptococcus pneumonia

Answer 43

**Cryptococcus neoformans** - Opportunistic fungal infection carried by birds Forms space occupying lesions (clumps of fungus) in the lungs, brain, skin, eyes **NB** - Mycobacterium avium intracellulare has nothing to do with birds, it is a water-born infection; put in exam question as a trap

Question 44

**35 yo injecting drug user, CD4 of 300, temperature 38** Adenovirus Aspergillus fumigatus Cryptococcus neoformans Cytomegalovirus Haemophilus influenzae Histoplasma capsulatum Mycobacterium avium cellulare Mycobacterium TB Pneumocystis jiroveci Pseudomonas aeruginosa Staphylococcus aureus Streptococcus pneumonia

Answer 44

**Staphylococcus aureus** Staph lives on skin normally, can cause problems if wound present, IV lines, IV injections Characteristic thing on CXR à cavitating consolidations (air spaces)

Question 45

**40 yo man, returned from Thailand 2 months earlies, presents with generalised rash, systemic malaise, generalised lymphadenopathy and low-grade fever. Admits to unprotected sex with a girl he met in a bar in Bangkok.** Burkitts lymphoma Chancroid Epstein Barr virus Genital herpes Hodgkin’s lymphoma Kaposi’s sarcoma Lymphogranuloma venereum Non Hodgkin’s lymphoma Persistent generalised lymphadenopathy Rubella Sarcoidosis Syphilis

Answer 45

**Syphilis** **Secondary syphilis rash** --> Maculopapular rash, widely disseminated, non-itchy, red, involves palms and soles (which other rashes don’t) à not everybody gets it, depends on the immune response **Timecourse** --> 4-6 weeks for secondary syphilis since exposure

Question 46

**25 yo man, recently diagnosed with HIV, prominent, non-tender glands in neck and axillae. Otherwise well with CD4 of 550 and viral load of 25000 copies per ml.** Burkitts lymphoma Chancroid Epstein Barr virus Genital herpes Hodgkin’s lymphoma Kaposi’s sarcoma Lymphogranuloma venereum Non Hodgkin’s lymphoma Persistent generalised lymphadenopathy Rubella Sarcoidosis Syphilis

Answer 46

**Persistent generalised lymphadenopathy (PGL)** Does not do anything, entirely benign Can occur anywhere where lymph nodes are Important to document that it is there Sometimes goes away, sometimes does not

Question 47

**30 yo man, HIV+, malaise, weakness, anaemia. Low-grade fever and increasingly unwell over several weeks. CD4 of 100. CT scan reveals enlarged hilar and para-aortic lymph nodes.** Burkitts lymphoma Chancroid Epstein Barr virus Genital herpes Hodgkin’s lymphoma Kaposi’s sarcoma Lymphogranuloma venereum Non Hodgkin’s lymphoma Persistent generalised lymphadenopathy Rubella Sarcoidosis Syphilis

Answer 47

**30 yo man, HIV+, malaise, weakness, anaemia. Low-grade fever and increasingly unwell over several weeks. CD4 of 100. CT scan reveals enlarged hilar and para-aortic lymph nodes.** **Non Hodgkin’s lymphoma** - most common lymphoma in HIV

Question 48

40 yo man, multiple purple-brown lesions on the trunk and face. Oral lesions. HIV positive, CD4 of 53. Cause?

Answer 48

**Kaposi’s sarcoma** Can get it anywhere -->** tip of the nose is quite common, gut, viscera (e.g. lung), skin** AIDS defining diagnosis Caused by Human Herpes Virus 8 (HHV8) so Kaposi’s is a virally derived cancer It is a cancer, but behaves like opportunistic infection

Question 49

What is the next appropriate management step? Why? [1] **Advanced HIV, headache, fever, recent grand mal seizure. CT head unremarkable.**

Answer 49

**Lumbar puncture** - Looking for **cryptococcal meningitis.** Need to check CT head before lumbar puncture, because doing an LP on someone with raised ICP will kill the pt

Question 50

What is the next appropriate management step? Why? [1] **Pt with CD4 of 50, SOB, non-productive cough and fever. CXR normal.**

Answer 50

**Bronchoscopy and alveolar lavage** - Looking for **PCP** - So majority of people will have abnormal CXR with this actually but this is not impossible; mean exam question

Question 51

What is the next appropriate management step? Why? [1] **IVDU, with HIV and hep C, AST twice the normal range**.

Answer 51

Liver biopsy

Question 52

What is the next appropriate management step? Why? [1] **HIV+ pt, CD4 of 75, 2 right hemispheric lesions unchanged after 2 weeks tx with sulphadiazine and pyrimethamine (tx for toxoplasmosis)**

Answer 52

**Brain biopsy** - We don’t do biopsies lightly Point is here, that you’ve made a diagnosis and it is not responding to treatment, so we need to find out what is going on - This is likely to by a **lymphoma** Brain lumps in HIV patients: - **Toxoplasmosis** (multiple ring-enhancing lesions with swelling around them) - **lymphoma** (single non-enhancing lesion) Toxoplasmosis and lymphoma do not always fit text-book descriptions, they can look alike to each other at times

Question 53

What is the next appropriate management step? Why? [1] **HIV+ pt, CD4 of 25, severe retrosternal odynophagia, low grade fever, no oral candida.**

Answer 53

**Upper gastro-intestinal endoscopy** Looking for: - **Cytomegalovirus**, **Oesophageal** **candidiasis** (but if not in the mouth, then unlikely to be further down the GI tract), **Kaposi**’s **sarcoma** (but does not usually cause pain)

Question 54

Select the most likely diagnosis for pt with confusion. **47 yo man acting inappropriately for several months; uncharacteristically aggressive and moody. Stopped all antiretroviral dxs 6 months earlier, complaining of intolerable side effects. O/E apyrexial, no focal neurology. 7/10 MMSE with mistakes on memory questions. CD4 of 56, bloods normal. CT brain shows generalised cerebral atrophy and widened sulci. CSF pressure, cell count, protein, glucose, Z-N stain and India ink stain are all normal** Alcohol intoxication CMV encephalitis CNS lymphoma Cryptococcal meningitis HIV associated dementia Progressive multifocal leukoencephalopathy Toxoplasmosis Tuberculosis meningitis

Answer 54

**HIV associated dementia** Tx à restart antiretroviral therapy to get rid of viral replication in the brain; some ppl improve a bit, some will stabilise, for some it may have gone too far for any change; no specific dementia tx

Question 55

**32 yo lady from Zimbabwe, HIV+ diagnosed 4 wks before. 3 wk hx of worsening headache, neck pain with recent onset nausea and vomiting. O/E temperature 38.3 and mildly confused, photophobia, neck stiffness but no focal neuro signs. CT brain normal. CSF pressure is 30 cm H2O, analysis reveals 20 lymphocytes and positive India ink stain.** Alcohol intoxication CMV encephalitis CNS lymphoma Cryptococcal meningitis HIV associated dementia Progressive multifocal leukoencephalopathy Toxoplasmosis Tuberculosis meningitis

Answer 55

**Cryptococcal** **meningitis** Cryptococcus neoformans is a fungal organism, has a waxy coat on it. **Has (+)-ve India ink stain**, because of waxy coat it forms a halo around cell.

Question 56

35 yo man, recently diagnosed HIV, presents to A&E having had a witnessed grand mal seizure as his 1st fit. Has just begun low dose Cotrimoxazole and planning to start anti-HIV therapy soon. CD4 is 60. R-sided limb weakness, extensor plantar reflex, confusion, temp 37.5. CT brain shows solitairy, left frontal lobe mass without contrast enhancement.

Answer 56

**CNS lymphoma**

Question 57

**HIV man, hasn’t visited clinic for a while, 3 wk hx of fatigue, malaise, increasing unsteadiness when stands up and when walking. CD4 is 50. O/E alert, afebrile, no motor weakness, wide based gait, imprecise heel-shin movement and past-pointing on finger nose test. CT brain mild diffuse cerebral atrophy, MRI brain shows extensive low attenuation signal of the cerebellar white matter without contrast enhancement or mass effect.** Alcohol intoxication CMV encephalitis CNS lymphoma Cryptococcal meningitis HIV associated dementia Progressive multifocal leukoencephalopathy Toxoplasmosis Tuberculosis meningitis

Answer 57

**Progressive multifocal leukoencephalopathy** No mass effect à not a space occupying lesion **Cause**: **reactivation** of **JC virus in brain because of immunosuppression** Infects the **white** **matter** (hence the name **LEUKOencephalopathy**)

Question 58

**42 yo woman, in A&E with her long term HIV+ partner. Presents with 1 month hx confusion, headache, difficulty watching TV, some injuries to her left arm caused by knocking into objects. O/E confused, low fever, oral candida, left eye temporal visual field defect and extensive perivascular exudates and haemorrhages on retinal examination. CT brain shows periventricular contrast enhancement and mild atrophy. She refuses lumbar puncture and is given presumptive treatment.** Alcohol intoxication CMV encephalitis CNS lymphoma Cryptococcal meningitis HIV associated dementia Progressive multifocal leukoencephalopathy Toxoplasmosis Tuberculosis meningitis

Answer 58

**42 yo woman, in A&E with her long term HIV+ partner. Presents with 1 month hx confusion, headache, difficulty watching TV, some injuries to her left arm caused by knocking into objects. O/E confused, low fever, oral candida, left eye temporal visual field defect and extensive perivascular exudates and haemorrhages on retinal examination. CT brain shows periventricular contrast enhancement and mild atrophy. She refuses lumbar puncture and is given presumptive treatment.** Alcohol intoxication **CMV encephalitis** CNS lymphoma Cryptococcal meningitis HIV associated dementia Progressive multifocal leukoencephalopathy Toxoplasmosis Tuberculosis meningitis