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DipHIV > Vaccinations/malignancy/transplant > Flashcards

Vaccinations/malignancy/transplant Flashcards

1
Q

Which HIV positive people are at increased risk of severe COVID outcomes?

A

Pregnant women
Nadir CD4<200
CD4<350 or ongoing viraemia

Should offer vaccination to all including low CD4 although immune response may be lower magnitude

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2
Q

Live (replicating) viruses that should not be given when CD4<200:

A

MMR
Chickenpox
Shingles
Yellow fever

Postpone until CD4 improved, ideally >350, if 200-350 depends on risk of the disease
Interval of 4 weeks between live vaccines in the immunocompetent

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3
Q

Hepatitis A information

A
  • Faeco-oral transmission
  • Jaundice in 1-5%. children but 70-80% adults, fulminant hepatitis rare <1%
  • Those with chronic liver disease at risk of severe complications
  • If high risk contact then HAV vaccine plus HNIG within 14 days, especially if CD4<200
  • Standard vaccine dose is fine for CD4>350 = 2 doses 6-12 months apart
  • If CD4<350 give 3 doses 0, 1 and 6 months
  • Boosting dose 10 yearly if at ongoing risk
  • Could screen for immunity prior
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4
Q

Persistence of HBV depending on age you get it:

A
  • HBV persistent in up to 90% of infants infected perinatally
  • 25-50% of children age 1-5
  • 1-5% of immunocompetent adults and children

HIV increases risk of HBV and risk of chronicity

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5
Q

Factors that reduce immune response to hep B vaccine:

A

Age>40
Male
Haemodialysis
Smoking
Obesity
Immunocompromise including HIV

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6
Q

How to vaccinate for Hepatitis B in HIV positive

A
  • Double dose 40mcg of Energix or HBvaxPRO (yeast based) normal 20mcg of Fendreix
  • 4 doses at 0,1,2 and 6 months
  • (Only consider ultra rapid course at 0, 1 and 3 weeks with normal dose vaccine if imperative for vaccination/compliance concerns and CD4>500)
  • Measure HbSab at 4-8 weeks:
  • If <10 give 3 further doses at monthly intervals
  • If between 10-100 may give 1 booster and re-test in 4-8 weeks
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7
Q

Following high risk exposure to HBsAg positive source

A
  • If evidence of current or past infection no prophylaxis needed
  • If vaccinated with HbSAb>10 offer one booster dose, and if CD4<200 also HBIG
  • Non responder to previous vaccination should be offered booster vaccine and HBIG regardless of CD
  • Not vaccinated or uncertain -> offer vaccine course 0, 1, 2,6 and HBIG regardless of CD4
  • If HBIG indicated give 2 doses 1 month apart
  • Post exposure prophylaxis should be given within 7 days, up to 6 weeks may be considered
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8
Q

BHIVA recommendations and suggestions for HPV vaccination?

A

Recommend (regardless of CD4, VL, ART):
- all HIV positive up to age 26
- all MSM up to age 40
Suggest:
- all women up to age 40
- if ART naive and CD4<200 may defer until established on ART

3 doses of quadrivalent given at 0, 1-2 months and 6 months
If schedule interrupted, complete it rather than restart

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9
Q

Flu vaccine recommendations

A
  • Annual between Sept and early Nov (although may be benefit until Match) with non replicating virus
  • Offer vaccine to close contact of profoundly immunocompromised
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10
Q

Measles screening and management of exposure

A

Screen for measles IgG
If seronegative and CD4>200 offer 2 doses MMR at least 1 month apart
Postpone if not yet on ART
After a recognised exposure to measles:
- Test IgG within 3 days
- If measles seronegative and CD4>200: MMR within 3 days of context or NHIG within 6 days
- If measles seronegative and CD4<200L HNIG within 6 days (or IVIG up to 18 days)

(NB women of childbearing age screen for rubella and offer MMR if negative and CD4>200 and not pregnant)

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11
Q

Meningococcus vaccination:

A
  • Usual vaccination is MenC as part of infant program then MenACWY recommended for adolescents/uni
  • Offer these if <25 and not previously vaccinated
  • For asplenia give MenC, Men B and/or MenACWY\
  • Give 2 vaccines at 2 months interval
  • Close contacts offer Abx and vaccination
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12
Q

Step pneumonia (pneumococcus)

A
  • Most frequent bacterial co-infection with Flu
  • Incidence has decreased with ART but HIV pos still have 40x higher risk than HIV neg
  • HIV positive adults should receive a single dose of PCV13 regardless of CD4 (at least 3 months after any use of PPV23)
  • HIV positive adults who meet indications for PPV23 vaccination with national program should also get single PPV23
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13
Q

Small pox vaccination

A

Generally just e.g. lab workers
If non urgent can give the non replicating Imvanex 2 doses 1 month apart regardless of CD4
If urgent, can give replicating if CD4>200, if <200 need to be careful, can give it if CD5>50, if <50 unlikely to respond so give antirvirals

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14
Q

Recommendations for VZV testing/vaccination

A
  • Test for VZV IgG
  • If negative and CD4>200 give 2 doses of chickenpox vaccine 3 months apart and check serology 4-6 weeks later
  • If VZV IgG positive with CD4>200 can be offered VZV vaccine (Zostavax) in line with national guidelines if >70 years
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15
Q

What to do if VZV exposed and IgG negative

A
  • If CD4<200: give VZIG asap and antivirals, acyclovir 800mg QDS or valaciclovir 1g TDS 7 days after exposure for 7 days
  • If CD4<400 give VZIG as soon as possible, if not available give antivirals
  • If CD4>400 give varivax vaccine within 3 but up to 5 days post exposure and again at 3 months
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16
Q

Post anthrax exposure

A

Ciprofloxacin and vaccinate

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17
Q

Contact of diphtheria

A

Erythromycin prophylaxis, and single reinforcing dose if already immunised or full course if not immunised

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18
Q

Haemophilus influenza serotype B

A
  • Increased risk of invasive disease if HIV positive
  • Household contacts given prophylaxis e.g. rifampicin
  • If asplenic give dose whether previously vaccinated or not and regardless of CD4/ART/VL, e.g. Him/MenC
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19
Q

Hepatitis A vaccination and post exposure

A
  • If high risk exposure then HAV vaccine plus HNIG within 14 days
  • Vaccination is 2 doses 6-12 months apart if CD4>350
  • CD4<350 then given 3 doses 0, 1 and 6 months
  • Booster 10 yearly
  • May be advisable to screen for immunity prior
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20
Q

Which HPV usually cause warts and cancer

A
  • 90% warts 6 and 11
  • 60% cancers 16 and 18
21
Q

Measles vaccination guidelines

A
  • Screen for IgG
  • If seronegative and CD4>200 offer 2 doses of MMR at least 1 month apart, postpone if not yet on ART
22
Q

Measles post exposure:

A
  • Screen for measles IgG within 3 days
  • If seronegative, CD4>200: MMR vaccine within 3 days of contact or NHIH within 6 days
  • If measles seronegative and CD4<200: HNIG within 6 days, can consider it up to 18 days
23
Q

Rubella screening

A
  • Screen all women of child bearing age
  • if CD4>200 and not pregnant, give MMR
24
Q

Streptococcal pneumoniae vaccination

A
  • All HIV positive should receive a single dose of PCV13 regardless of CD4 (at least 3 months after any use of PPV23)
  • HIV positive adults who meet indications for PPV23 vaccination (e.g. >65 or other co-morbidity) should also get single PPV-23
  • No repeats necessary
25
Q

Streptococcal pneumoniae vaccination

A
  • All HIV positive should receive a single dose of PCV13 regardless of CD4 (at least 3 months after any use of PPV23)
  • HIV positive adults who meet indications for PPV23 vaccination (e.g. >65 or other co-morbidity) should also get single PPV-23
  • No repeats necessary
26
Q

Rabies PEP

A
  • Nearly 100% effective if given <12-24 hours
  • Vaccine is the mainstay with rapid vaccination 0, 3, 4, 7, 14 and 30 days
  • If already had some vaccine then 2 doses 0 and 3-7 days
  • Sometimes HRIG at the wound
27
Q

BCG

A

Do not give in HIV

28
Q

HIV specific renal transplant inclusion criteria:

A
  • Good compliance with ART
  • CD4>200 last 6 months
  • VL<50 for last 6 months
29
Q

HIV specific renal transplant exclusion criteria:

A
  • CD4<200
  • VL detectable
  • Non adherence
  • History of PML ever
  • Extracutaneous KS
  • EBV and HHV8 driven disorders e.g. MCD
  • More than 3 class resistance and lack of future options
30
Q

General exclusions from renal transplant:

A
  • Previous or current infections at high risk reactivating
  • HTLV 1
  • Advanced cardiopulmonary disease
  • History of neoplasms except solid tumours adequately treated with >5 disease free years
  • Significant HPV cervical or anal disease including CIN/AIN III and in situ
  • Hepatitis cirrhosis, e.g. F4
  • Pregnancy
31
Q

Pre transplant immunisations

A
  • Recommend Hep b if abs<10, HAV, PPV23, VZV (if CD4>200), Flu annually
  • Suggested that DTP to all (diptheria, tetanus, pertussis), MMR if non immune to measles and HPV to those at risk
32
Q

Post transplant prophylaxis

A
  • HIV transplant recipients lifelong PCP prophylaxis
  • If recipient CMV negative and donor positive then minimum 3 months CMV prophylaxis, if recipient CMV positive 3 months prophylaxis or PCR surveillance
  • Toxo IgG positive with CD4<200 lifelong prophylaxis
  • CD4<50 MAC prophylaxis
33
Q

AIDS defining cancers

A
  • KS
  • High grade B cell non Hodhgkin lymphoma
  • Cervical cancer
34
Q

KS cells stain for endothelial cells with which markers?

A

CD34
CD31
Identification of HHV8 in lesions using a monoclonal antibody again LANA (HHV8 latent nuclear antigen) is the most useful immunostaining technique

35
Q

Poor prognostic factors in KS

A
  • Tumour associated oedema or ulceration
  • Extensive oral disease (not confined to palate)
  • Gastrointestinal KS or other non nodal viscera
  • CD4<150
  • History of HIs and/or thrush
  • ‘B’ symptoms present
  • Performance status <70
  • Other HIV related illness
36
Q

Side effects of liposomal doxorubicin (Caylex)
Given as infusion 3 weekly, overall response rate of 76% in HIV

A
  • Grade IV neutropenia 5%, risk of infection
  • Hand feet syndrome (redness/soreness)
  • GI upset
  • Rash
  • Les commonly hairloss
  • Rarely cardiomyopathy with liposomal
  • Does not appear to suppress CD4
37
Q

Why is paclitaxel second line?

A
  • More neutropenia and alopecia with comparable progression free survival
  • Need to give steroids prior to prevent allergic reaction
38
Q

DLBCL treatment

A

R CHOP

39
Q

Burkitt’s treatment

A

CODOX-M/IVAC, hyperCVAD

40
Q

EBV DNA in CSF

A
  • Very high sensitivity and specificity for PCSNL (?in the setting of brain lesion)
  • Negative does not exclude PCSNL though
40
Q

EBV DNA in CSF

A
  • Very high sensitivity and specificity for PCSNL (?in the setting of brain lesion)
  • Negative does not exclude PCSNL though
41
Q

Diagnosis of PCNL

A
  • CT/MRI/SPECT
  • LP for cytology and EBV
  • Brain biopsy sometimes
  • Look for systemic disease with CTCAP
  • SPECT showing high uptake and/or positive EBV DNA on CSF has very high sensitivity so can avoid biopsy
  • if hypoactive lesion and negative EBV DNA on CSF then empiric toxoplasmosis treatment
  • Discordant SPECT/PCR -> brain biopsy
  • Ring enhancement may be seen in up to 50%
42
Q

Treatment of PCNSL

A
  • Prognosis dismal
  • ART
  • Steroids for symptoms
  • Consider IV high dose methotrexate
43
Q

Treatment of Hodgkin lymphoma

A
  • ABVD +/- radiotherapy
44
Q

OI prophylaxis in chemotherapy

A
  • Septrin 480mg OD
  • Fluconazole 50mg OD
  • Valaciclovir 500mg BD or acyclovir 400-800mg bD
  • Azithromycin 1250mg/week

NB in KS reviewing Caelyx not at increased risk of CD4 decline so not needed unless already on

45
Q

PIS and vinblastine

A

Neurotoxicity and neutropenia

46
Q

Treatment of multi centric Castleman’s disease

A
  • Rituximab
47
Q

Diagnosis of MCD

A
  • CTCAP +/- PET +/- bone marrow
  • Biopsy: characteristic onion skin appearance, and HHV8 expression (LANA) and IgM lamda
  • Serum HHV8 DNA significantly higher than in KS
  • Rise in HHV8 can predict relapse
  • 88% 5 year survival with treatment
  • Can be relapsing remitting

DipHIV (8 decks)

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