Aids-Opportunistic Infections

Front 1

do most people die from an HIV infection?

Back 1

no, they die due to a suppressed immune function and resulting infective illness

Front 2

between what CD4 count is a patient at risk for Kaposi's Sarcoma

Back 2

~300

Front 3

between what CD4 count is a patient at risk for PCP & Herpes simplex

Back 3

~200

Front 4

between what CD4 count is a patient at risk for oral candidiasis

Back 4

300-250

Front 5

between what CD4 count is a patient at risk for herpes zoster

Back 5

~350-300

Front 6

between what CD4 count is a patient at risk for non-hodgkins lymphoma

Back 6

250-200

Front 7

between what CD4 count is a patient at risk for cryptococcus and toxoplasmosis?

Back 7

150-100

Front 8

between what CD4 count is a patient at risk for MAC and CMV?

Back 8

100-50

Front 9

when should one start/stop PRIMARY prophylaxis for PCP?

what about secondary?

Back 9

PRIMARY: start CD4<200, stop CD4>200x3mo

SECONDARY: start CD4<200, stop CD4>200x3mo

Front 10

when should one start/stop PRIMARY prophylaxis for toxoplasmosis?

what about secondary?

Back 10

PRIMARY: start CD4<100 & IgG+ (+ serology); stop CD4>200x3mo

SECONDARY: start CD4<200; stop CD4>200x6mo

Front 11

when should one start/stop PRIMARY prophylaxis for MAC?

what about secondary?

Back 11

PRIMARY: start CD4<50; stop CD4>100x3mo

SECONDARY: start CD4<100; stop CD4>100x6mo

Front 12

when should one start/stop PRIMARY prophylaxis for candidiasis?

what about secondary?

Back 12

N/A -- no prophylaxis required, treat as pt acquires it

Front 13

when should one start/stop PRIMARY prophylaxis for cryptococcus?

what about secondary?

Back 13

PRIMARY: NOT recommended (consider at CD4<50) -- stop: n/a

SECONDARY: CD4<100-200; stop CD4>100-200x6mo

Front 14

when should one start/stop PRIMARY prophylaxis for histoplasmosis?

what about secondary?

Back 14

PRIMARY: consider start CD4<50; stop n/a

SECONDARY: life long suppressino

Front 15

when should one start/stop PRIMARY prophylaxis for CMV?

what about secondary?

Back 15

PRIMARY: consider start CD4<50; stop n/a

SECONDARY: consider start CD4<100-150; stop CD4>100-150x6mo

Front 16

what is the clinical presentation of PCP?

Back 16

pulmonary dysfunction (pneumonia)

early disease: mild sx-mild cough, exertional dyspnea, normal chest x-ray

severe disease consistent with BILATERAL pneuml: fever, nonproductive cough, SOB, diffuse pulmonary infiltrates

Front 17

what is the preferred treatment regimen for PCP?

Back 17

high dose bactrim (15-20mg/kg/day in 3-4 divided doses) --- 2 bactrim DS tid

Front 18

what about corticosteroid use in PCP?

Back 18

add on if PO2 <70mmHg

drug: methylprednisone, prednisone

Front 19

if pt has a sulfa allergy, can bactrim still be used for tx of PCP? what are some s/sx of bactrim intolerance?

Back 19

sulfa allergy -- do NOT use bactrim

s/sx: fever, rash, neutropenia, anemia, thrombocytopenia, hepatits, pancreatitis, interstitial nephritis

Front 20

if a pt is bactrim intolerant, what are other tx options for PCP?

Back 20

dont memorize - just be able to recognize that they are used SECOND line:

clindamycin + primaquine

trimethoprim + dapsone

atovaquone

pentamide

Front 21

what is the preferred regimen for PCP prophylaxis? at what CD4 level should pt undergo chemoprophylaxis?

Back 21

bactrim DS or SS po QD or DS TIW (less efficacious)

Front 22

How is PCP diagnosed?

Back 22

respiratory culture and symptoms

Front 23

this disease is associated with undercooked pork, lamb, beef, transplacental spread, and ingestion of cat-derived oocysts

Back 23

toxoplasmosis

Front 24

toxoplsmosis is manifested via:

Back 24

CNS*****: encephalitis, abcess

lung: pneumonitis

eye: retinochoroiditis

Front 25

CNS manifestations in pts w/toxoplasmosis are:

Back 25

fever, focal neurologic defect

ring enhancing lesions on MRI

Front 26

toxoplasmosis treatment regimen

Back 26

pyrimethamine + leucovorin + sulfadiazine x 3-6wks

Front 27

why is leucovorin part of the treatment regimen for toxoplasmosis?

Back 27

lecovorin is added to decrease pyrimethamine toxicity (its a folic acid savior)

Front 28

what about maintenance therapy for toxoplasmosis? how long should the patient be on 3 drug treatment regimen?

Back 28

may decrease dosage from treatment regimen for maintenance;

should be in place until CD4 count is restored (to >200x6mo)due to high relapse rate

Front 29

what regimen is used for toxoplasmosis prophylaxis???

Back 29

primary: bactrim DS or SS po QD

secondary: maintenance therapy with pyrimethamine+sulfadiazine+leucovorin

Front 30

what should be done before beginning toxoplasmosis prophylaxis?

Back 30

1. test IgG to Toxoplasma (T. gondii) to asses previous exposure -- IgG should be +
2. CD4 count should be <100

stop w/CD4>200x3mo with primary prophylaxis

Front 31

What is the clinical presentation of oropharyngeal Candidiasis?

Back 31

oral: creamy white patches on the tongue and other mucosal sufaces

pts may experience pn w/subsequent decrease in food and fluid intake

esophageal: painful swallowing, obstructed swallowing, sub-stemal pn

vulvovaginal: creamy, white abnormal discharge, pruritis, pn, dysuria, dyspareunia

Front 32

pathogen that causes cadidiasis

Back 32

Candida albicans

but there are exceptions: dubliniesis, glabrata, kruseii

Front 33

how does treatment differ for mild vs. moderate to severe OPCC?

Back 33

mild: topical therapy

moderate to severe, esophagitis: ALWAYS systemic therapy

Front 34

what are the treatment options available for OPC?

Back 34

AZOLES: fluconazole**, miconazole, itraconazole, voriconazole

POLYENES: nystatin and amphotericin B

ECHINOCANDINS: caspofungin, anidulafungin, micafungin

Front 35

what is the MOA of azoles?

Back 35

inhibit fungal CYP450-dependent ergosterol synthesis, resulting in impaired cell membrane integrity

Front 36

what is the MOA of polyenes?

Back 36

bind to ergosteral and disrupt fungal cell membrane

Front 37

what is the MOA of echinocandins?

Back 37

inhibit beta 1,3-glucan synthase, disrupting cell wall synthesis

Front 38

what are the advantages/disadvantages of using azoles for OPC?

Back 38

IV, PO formulations

fewer side effects

drug interaction potential

Front 39

what are the advantages/disadvantages of using polyenes for OPC?

Back 39

Nystatin is available oral or topical

amphotericin B has MANY ae's including renal dysfunction, infusion reactions, electrolyte abnormalities

Front 40

what are the advantages/disadvantages of using echinocandins for OPC?

Back 40

they are safe, avail on IV, and VERY expensive

*used when someone has developed resistance to azoles or poplyenes

Front 41

treatment regimens for THRUSH

Back 41

clotrimazole oral troches 10mg 5x/day until lesions resolve

nystatin 500,000units gargled/swich and swallow 4-5x/day

fluconazole po 100+mg/day

other options = for resistant or unresponsive OPC: itraconazole, voriconazole, oral amphotericin B, IV amphotericin

tx until symptoms resovlve (usually 7-14d)

Front 42

treatment regimens for esophageal candidiasis

Back 42

do NOT use topical (nystatin, clotrimazole)

Treat systemically for 14 to 21 days (Most pts respond in 5 days; Consider increasing dose or changing agent if response not seen)

Fluconazole 200mg/day and up
800mg – 1600mg may be used in certain patients

Alternative regimens:
Itraconazole, voriconazole, amphotericin B, echinocandins

Front 43

is prophylaxis required for candida? if so - at what CD4 count?

Back 43

Primary: Not routinely recommended

Secondary:
Consider with history of esophageal candidiasis

Fluconazole 100-200mg/day

May consider with many repeat occurrences of oral thrush

candidiasis is more frequent with CD4<100

Front 44

diagnosis of candidiasis is made by doing what?

Back 44

clinical exam, KOH test

Front 45

this OI is caused by inhalation, then hematogenic dissmination of aerosolized organism...which is found in pigeon droppings and nesting places

Back 45

Cryptococcus neoformans

Front 46

S/SX of Cryptococcal neoformans

Back 46

most commonly presents as meningitis** (low grade fever*, HA*, decreased cognitive function*, minimum nuchal rigidity & seizures may occur)

pulmonary disease is also possible: cough, fever, SOB, chest pn, etc.

Front 47

diagnosis 101 of cryptococcal neoformans

Back 47

CSF culture**, clinical symptoms, elevated CSF opening pressure (stick needle in pts back)
india ink stain**

Front 48

why is it VERY important to treat cryptococcal meningitis?

Back 48

it has a HIGH mortality rate!

Front 49

treatment regimen for cryptococcal meningitis

Back 49

Induction: Amphotericin B x 14d
(Flucystosine speeds clearance of yeast and helps prevent relapse; no initial improvement in mortality noted)


Consolidation: fluconazole 400mg/day x 8 weeks or until CSF sterile

Suppressive/maintenance: fluconazole 200mg/day
(Continue until immune reconstitution occurs with HAART)

Front 50

is prophylaxis warranted for cryptococcal meningitis?

Back 50

Primary: NOT routinely recommended
If done, use 100-200mg fluconazole at CD4<50

Secondary:
Lifelong UNTIL immune reconstitution
May stop with CD4≥100-200 for 6+ months, completed treatment course, and asymptomatic

Front 51

this disease is caused by an organism that: Present in soil and water , domestic and farm animals, birds, foods, and some tobacco products – *we are exposed to it all the time*

Organism gains access through the gut or lungs, then spreads hematogenously

Back 51

Mycobacterium avium complex

comprised of M. avium, M. intracellulare (MAI)

Front 52

what organs are involved and what are the s/sx of MAC?

Back 52

multiple organ involvement

s/sx - Non-specific for the most part
Weight loss, intermittent fevers, chills, night sweats, abdominal pain, diarrhea, weakness, anemia
No pulmonary symptoms*



CD4 <50 = more common than you might think
MAC = more of a dissmenated bug
tuberculosis = pulmonary dysfunction  respiratory failure
MAC = likes to get into other places in body; bone marrow, GI tract, major organs i.e. liver  severe anemia, severe GI distress (diarrhea, wasting)
Most get a bone marrow biopsy – most common diagnosis w/MAC

Front 53

therapy for MAC preferred regimens:

Back 53

Clarithromycin PO + ethambutol PO

Azithromycin IV/PO + ethambutol PO

Front 54

therapy for severe MAC:

Back 54

Use one of the preferred regimens + one of the following: (3 drugs)

Rifabutin (3rd agent), quinolone antibiotic, or amikacin

Front 55

primary MAC prophylaxis: when, how?

Back 55

*Primary*:
Start with CD4<50
D/C if CD4≥100 x 3+ months

Agents:
Azithromycin 1200mg qwk, clarithromycin 500mg bid, or rifabutin 300mg day

Azithromycin easiest, safest, and most widely used

Clarithromycin and rifabutin possess incr toxicity and drug interaction potential

Front 56

secondary MAC prophylaxis: when, how?

Back 56

Secondary:
May stop if patient’s CD4≥100 for 6+ months, has completed at least 12 months of maintenance therapy, and asymptomatic.

Agents:
Macrolide (azitho/clarithro) + ethambutol ± rifabutin

Front 57

MAC diagnosis:

Back 57

blood culture, bone marrow biopsy, stool culture