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52 Cards in this Set
- Front
- Back
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HIV def
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-based on the presence of OI and/or malignancies in the absence of other causes of immune deficiency
-transmission: exposure of blood, blood products, body fluids or tissues |
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what happens during acute infx
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-after percutaneous/mucosal exposure local replication of virus occurs
-tissue macrophages &/or dendritic cell host T-cells will attempt to kill local infx -if the local infx cannot be controlled at this point, within 2 or 3 days of replication of the virus will occur in lymphnodes. Viremia occurs in 305 days -if you get stuck take 1st dose of HIV meds right away!!!! |
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What constitutes blood, blood products, body fluids or tissues
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1. breast milk
2. semen 3. vaginal secretions 4. organs used in transplant 5. bone marroe 6. CSF 7. amniotic fluid 8. blood 9. blood factors |
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IV drug use
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-accounts for about 25% of all HIV transmission in the US
-The sharing of needles, syringes and other equipment is a major route of transmission |
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non-IV drugs increase the rate of transmission...
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1. crack
2. ecstasy 3. alcohol 4. snorting heroine or cocaine 5. xanax 6. crystal meth (Tin, Crys) 7. ketamine 8. GHB |
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Transfusion/transplant of blood products or organs
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-The screening of blood for antibodies for HIV started as soon as antibody testing was available in March 1985. Today antibody testing as well as viral PCR testing is done on all tissues used in transfusion/transplant.
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Vertical transmission
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-90% of children who are HIV + are infected parentally
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facilitating factors in transmission
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1. high maternal viremia
2. low maternal CD4 count 3. placental membrane inflammation 4. high maternal CD8 count |
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reduction of transmission
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-ACTG 076 showed the use of AZT was safe and effective in reducing the rate of vertical HIV transmission
-today triple ART is used during preg, AZT is given during labor and to the baby after birth -never used Sustiva during preg! |
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sexual transmission
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-rate of transmission in men who have sex with men (MSM) was as high as 52%
-with edu rates had dropped however rates of HIV new infx as well as rates of syphilis are up |
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rate is increased by
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1. receptive anal sex with multiple partners
2. rectal trauma 3. use of enemas 4. history of anorectal GC and/or syphilis or other ulcerative STD such as HSV |
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who should be HIV tested
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1. anyone with an STD
2. anyone with high risk behavior -IVDA/IVDU -MSM unprotected -recipients of blood or blood products before 1985 -someone who exchanges sex for drugs or money 3. all preg women 4. anyone with active TB 5. any with recurrent and/or resistant vaginal candida 6. any women with recurrently abnl pap smears 7. anyone with clinical lab findings suggestive of HIV |
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When to treat
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1. CD4 below 350
2. viral load above 100,000 3. All HIV + pregnant women 4. anyone with HIV associated nephropathy 5. persons co-infected with Hep B -consider tx in anyone with a CD4 count b/t 350 and 500 that do not meet the criteria mentioned above -treatment for pts with CD4 above 500 is optional |
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What labs do we start with?
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1. HIV AB test
2. CD4/T cells 3. HIV viral load 4. CBC, SMA8, lipids, liver enzymes, Hep A, B and C 5. RPR 6. PPD 7. Anti-toxoplasma gondii IgG 8. pap smear 9. resistance testing 10. STD screen for all pts |
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opportunistic infections
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-pulmonary
-brain -skin |
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pneumocystis carinii pneumonia PCP
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-Pneumocystis is found in many animals. It has characteristics of a protozoan however, mitochondrial RNA, cell structure is suggestive of a fungi. It occurs in 3 distinct forms: cyst, tachyzoite, and sporozoite. Human pneumocystis never been cultivated successfully.
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PCP clinical presentation
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-pulmonary dysfunction
-may have minimal sx: 1. mild cough 2. SOB with exercise 3. CXR may be nml or have interstitial infiltrates 4. ABG may be nml, may decompensate with exercise or walking, may be hypoxic |
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PCP diagnosis
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-BAL/bronchoaveolar lavage
-gallium scan -HRCT scan -induced sputum -sputum stained with: Giema, diff quick, toludine blue, methenamine silver |
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PCP labs
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-CD4 <2000
-if PO2< 70 mm start predinisone -if PO2 >80 may not need prednisone -WBC frequently nml or low -elevated LDH |
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PCP tx
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1. Bactrim DS oral
2. Bactrim IV 3. Mepron 4. Pentamidine (can cause DM) 5. Trimethaprim/Dapsone oral 6. Clindamycin/primaquine -tx is 21 days, If no improvement is seen in the first few days consider adding steroids, changing medication, re-evaluating diagnosis |
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Histoplasmosis
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-95% of cases of disseminated histoplasmosis occurs in persons with advanced disease (CD4 below 200)
-Localized pulmonary disease occurs in persons with CD4 above 300 -In immunocompetent patients recover usually occurs with in one month with out treatment due to an immune mediated response. -remember: Ohio/Missouri/Mississippi river valley |
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histoplasmosis presentation
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1. fatigue
2. wt loss 3. fever 4. cough 5. dyspnea 6. HSM 7. LAD 8. CNS infxs- 10-20% of cases 9. CSF can show high prot, low gluc, high WBC -corse is often insidious over 1-3 months but can be rapid and fatal |
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histoplasmosis GI manifestations
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1. Diarrhea
2. abd pain 3. intestinal obstruction or perforation 4. bleeding 5. peritonitis |
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histoplasmosis tissue stain
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Giemsalin
Eosin Gram stain Hematoxylin Wright Stain show yeasts and buds |
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histoplasmosis tx for the severely ill
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-hypoxia
-hypotension -AMS -coagulopathy -anemia -high LFT's -low WBC -hospitalize for tx with amphotericin B IV once pt improves start oral intraconazole |
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histoplasmosis tx if not severely ill
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-can treat with oral intraconazole or fluconizole or IV ampho B
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TB
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-leading cause of death world wide for person's with HIV
-extrapulmonary Tb seen with pts who have a CD4 of under 100 1. sites include lymphnodes 2. liver 3. bone marrow, GU and CNS 4. spine (potts dz) |
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skin testing: PPD
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-.1ml injected intradermally
-read 48-72 hrs later |
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positive PPD >/= 5mm indurations considered for
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1. HIV+
2. close contact to person with activeTB 3. a person with immune compromise due to other reason |
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+ PPD >/=10 mm induration
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1. IVDU/IVDA
2. residence in high congregate setting 3. recent arrival fro ma country where TB is prevalent 4. renal failure 5, malignancy |
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+ PPD >/=15 ml
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-for a person who has no risk for TB
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Tb presentation
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1. fever
2. chills 3. night sweats 4. productive cough 5. wt loss (comsumption) |
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TB CXR
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-upper lobe cavitary lesions, widened medisatinum and cavitary lesions most common in high CD4 counts
-if pts with low CD4 it is a more diffuse disease ex. miliary TB -pleural, LN, pericardial, kidney, bone especially spine involvement is possible |
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TB dx
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-sputum smear may show acid fast bacilli
-LN biopsy -abscess bx -cx takes 2 months to be final |
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Tb tx
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-for drug sensitive Tb 2 months of:
INH, rifampin, PZa, ethambutol -followed by 4 months of: INH, rifampin |
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for pts intolerant of PZA
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-then tx 9-12 months with INH, rifampin, ethambutol
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for pts intolerant to rifampin
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-treat 9-12 months with INH, PZA, ethambutol
*very common in pts who are tkaing methadone! |
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progressive multifocal leukoencephalopathy (PML)
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-caused by JC virus
-produced a progressive CNS deficit: motor, sensory, congnitive, visual |
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PML dx
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MRI: shows white matter lesions. Multiple large bright areas of demylenation, without contrast.
-NO MASS EFFECT CSF: not helpful Brain bx: demylenation of white matter |
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PML tx
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-no good direct tx
-Immune reconstitution with ART has proved helpful if diagnosis is made early enough |
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Cryptococcosis sx
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1 photophobia
2. nuccal rigidity 3. fever 4. visual changes 5. MS changes 6. skin lesions which look like warts, lesions resolve with tx |
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cryptococcis dx
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LP:
1. low glucose 2. high protein 3. elevated WBC 4. + cryptococcal antigen 5. + india ink stain |
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cryptococcis tx
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-diflucan
-intraconazole -amphotericin B |
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toxoplasmosis gondii
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-Primary infection via ingestion of infected meat or through fecal oral route. Primary infection is usually self limiting. May cause lymphadenopathy.
-reactivation infx: CNS most common, pneumonitis and retinochoroiditis possible |
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Toxo- CNS infx
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1. HA
2. confusion 3. AMS 4. focal neurologic deficits are very common 5. seizures 6. ataxia |
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toxo dx
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-brain bx
-Ct with contrast show ring enhancing lesions -CSF often not helpful -blood serology: toxo titers if + not helpful, if – you may consider other diagnosis especially if pt does not improve or gets worse. |
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tox tx
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-sulfadiazine
-folinic acid -pyrimethamine -if sulfa allergy: clindamycin in place of sulfadiazine |
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Kaposi's sarcoma
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-characterized by raised, violet colored lesions
-strongly linked with herpes virus 8 -best tx is getting the CD4 count up with antivirals |
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Toxo- CNS infx
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1. HA
2. confusion 3. AMS 4. focal neurologic deficits are very common 5. seizures 6. ataxia |
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toxo dx
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-brain bx
-Ct with contrast show ring enhancing lesions -CSF often not helpful -blood serology: toxo titers if + not helpful, if – you may consider other diagnosis especially if pt does not improve or gets worse. |
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tox tx
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-sulfadiazine
-folinic acid -pyrimethamine -if sulfa allergy: clindamycin in place of sulfadiazine |
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Kaposi's sarcoma
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-characterized by raised, violet colored lesions
-strongly linked with herpes virus 8 -best tx is getting the CD4 count up with antivirals |
