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60 Cards in this Set
- Front
- Back
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What are the seven main opportunistic infections associated with HIV/AIDS?
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Bartonellosis
Mycobacterial infections Pneumocystis jiroveci pneumonia (PCP) Cryptococcal infection Toxoplasmosis Histoplasmosis Cytomegalovirus (CMV) infection |
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Symptoms often chronic (months-years)
May involve any organ system BA of the skin: papular red vascular lesions, subcutaneous nodules; resembles Kaposi sarcoma Osteomyelitis (lytic lesions) Peliosis hepatica Systemic symptoms of fever, sweats, fatigue, malaise, weight loss |
BARTONELLOSIS
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What tests do you use to diagnose Bartonellosis?
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Tissue biopsy
Serologic tests (available through the CDC) Blood culture |
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How do you TX Bartenellosis? CNS and Non-CNS infections?
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Non-CNS infections
Preferred: Erythromycin Doxycycline Alternative: azithromycin or clarithromycin; fluoroquinolones CNS infections Preferred: doxycycline Alternative: azithromycin or clarithromycin Duration of treatment: at least 3 months |
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M avium is the causative agent in >95% of AIDS patients with this
Transmission believed to be via inhalation, ingestion, inoculation; person-person transmission unlikely Usually occurs in people with CD4 count <200 cells/µL Other risk factors: plasma HIV RNA >100,000 copies/mL, prior opportunistic infections, previous colonization with this. Symptoms: fever, night sweats, weight loss, fatigue, diarrhea, abdominal pain |
Mycobacterium Avium Complex
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What are the clinical manifestations of MAC?
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Physical exam or imaging: hepatomegaly, splenomegaly, or lymphadenopathy (paratracheal, retroperitoneal, paraaortic, less commonly peripheral)
Laboratory abnormalities: anemia, elevated liver alkaline phosphatase |
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How do you diagnose MAC?
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Isolation of organism from blood, bone marrow, lymph node, or other normally sterile tissue or fluid
Species identification is essential for differentiating MAC from TB Isolation from stool or sputum does not necessarily indicate invasive disease |
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How do you treat MAC?
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Strategy: initial treatment followed by chronic maintenance therapy
Initial treatment (≥12 months) At least 2 effective drugs, to prevent resistance Preferred: clarithromycin + ethambutol Alternative: azithromycin + ethambutol Potent ART – initiate or optimize To decrease risk of immune reconstitution reaction, consider delaying initiation of ART until 1-2 weeks after start of MAC therapy If moderate-severe symptoms of immune reconstitution reaction, consider NSAIDs, short-term corticosteroids (eg, prednisone 20-40 mg QD for 4-8 weeks) |
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What are the fungal infections that can become opportunistic infections in HIV/AIDS?
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Pneumocystis jiroveci pneumonia
Mucocutaneous candidiasis Cryptococcosis Histoplasmosis |
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Caused by P jiroveci (formerly P carinii)
Ubiquitous in the environment Initial infection usually occurs in early childhood Most cases occur in patients unaware of their HIV infection, in those who are not in care, and in those with advanced AIDS (CD4 count <100 cells/µL) |
Pneumocystis jiroveci pneumonia
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What are the following the risk factors for?
CD4 count <200 cells/µL CD4% <15% Prior PCP Oral thrush Recurrent bacterial pneumonia Unintentional weight loss High HIV RNA |
PCP
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Progressive exertional dyspnea, fever, nonproductive cough, chest discomfort
Subacute onset, worsens over days-weeks (fulminant pneumonia is uncommon) Chest exam may be normal, or diffuse dry rales, tachypnea, tachycardia (especially with exertion) Extrapulmonary disease seen rarely; occurs in any organ, associated with aerosolized pentamidine prophylaxis |
PCP clinical manifestations
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How is PCP diagnosed?
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Clinical presentation, blood tests, radiographs suggestive but not diagnostic
Hypoxemia: characteristic, may be mild or severe CXR: various presentations Chest CT, thin-section Patchy ground-glass attenuation May be normal |
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Definitive diagnosis requires demonstrating organism:
Induced sputum (sensitivity <50% to >90%) Spontaneously expectorated sputum: low sensitivity Bronchoscopy with bronchoalveolar lavage (sensitivity 90-99%) Transbronchial biopsy (sensitivity 95-100%) Open lung biopsy (sensitivity 95-100%) |
PCP diagnosis
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What is the TX for PCP?
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Duration: 21 days for all treatment regimens
Preferred: Trimethoprim-sulfamethoxazole (TMP-SMX DS) 2 tablets three times a day. Adjust dose for renal insufficiency Adverse reactions (seen in 20-85% of patients with AIDS): rash, Stevens-Johnson syndrome, fever, leukopenia, thrombocytopenia, azotemia, hepatitis, hyperkalemia |
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What is the TX for Severe PCP?
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Pentamidine 4 mg/kg IV QD
Recommended for patients intolerant of TMP-SMX or clinical failure with TMP-SMX; do not combine use Adverse reactions: pancreatitis, hypoglycemia, hyperglycemia, leukopenia, fever, electrolyte abnormalities, cardiac dysrhythmia |
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What is the TX for mild to moderate PCP?
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Dapsone 100 mg PO QD + TMP 15 mg/kg/day PO in divided doses TID
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What can be used as adjunctive therapy for PCP?
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Corticosteroids - Prednisone - Give as early as possible (within 72 hours)
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Oropharyngeal and esophageal candidiasis are common
Most common in patients with CD4 count <200 cells/µL Prevalence lower in patients on ART Vulvovaginal candidiasis Occurs in non-HIV-infected women; does not indicate immunosuppression In advanced immunosuppression, may be more severe or recur more frequently Usually caused by Candida albicans; other species (especially C glabrata) seen in advanced immunosuppression, refractory cases |
Mucocutaneous Candidiasis
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What are the clinical manifestations of mucocutaneous candidiasis?
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Oropharyngeal (thrush):
Pseudomembranous: painless, creamy white plaques on buccal or oropharyngeal mucosa or tongue; can be scraped off easily Erythematous: patches on anterior or posterior upper palate or tongue Angular cheilosis Esophageal: retrosternal burning pain or discomfort, odynophagia, fever; on endoscopy, whitish plaques with or without mucosal ulceration Vulvovaginal: creamy discharge, mucosal burning and itching |
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How do you diagnose mucocutaneous candidiasis?
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Oropharyngeal:
Usually clinical diagnosis KOH preparation, culture Esophageal: Clinical, with trial of therapy Endoscopy with histopathology and culture Vulvovaginal: Clinical diagnosis, KOH preparation |
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What is the TX for oropharyngeal thrush associated with mucocutaneous candidiasis?
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Oropharyngeal
Preferred : Fluconazole Itraconazole oral solution Clotrimazole troches Nystatin suspension or flavored pastilles If refractory to fluconazole: Itraconazole oral solution Amphotericin B IV |
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What is the TX for esophageal thrush associated with mucocutaneous candidiasis?
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Esophageal
Systemic therapy required Preferred (14-21 days): Fluconazole Itraconazole oral solution * Voriconazole * Caspofungin |
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What is the TX for vulvovaginal thrush associated with mucocutaneous candidiasis?
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Vulvovaginal
Uncomplicated: Topical azoles for 3-7 days Topical nystatin Itraconazole oral solution Fluconazole Prolonged or refractory: Continue treatment >7 days |
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Caused by Cryptococcus neoformans
Most cases seen in patients with CD4 count <50 cells/µL 5-8% prevalence in HIV-infected patients in developed countries before widespread use of effective ART Incidence much lower with use of ART |
Cryptococcosis
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What is the clinical manifestation of Cryptococcosis?
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Subacute meningitis or meningoencephalitis (most common presentation)
Fever, malaise, headache Neck stiffness, photophobia, or other classic meningeal signs and symptoms in 25-35% of cases Lethargy, altered mental status, personality changes (rarely) Acute illness with nuchal rigidity, seizures, focal neurologic signs observed in developing countries Disseminated disease is common: often pulmonary infection with or without meningeal involvement Cough, dyspnea, abnormal chest X ray Skin lesions Papules, nodules, ulcers, infiltrated plaques seen in disseminated disease |
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Cryptocooccus neoformans is found where?
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In the soil
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How do you diagnose Cryptococcosis?
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Detection of cryptococcal antigen (CrAg) in CSF, serum, bronchoalveolar lavage fluid (can have false-negative results)
India ink stain (lower sensitivity) Blood culture (positive in 75% of those with cryptococcal meningitis) Patients with positive serum CrAg should have CSF evaluation to exclude CNS disease CSF findings Mildly elevated protein, normal or slightly low glucose, few lymphocytes, many organisms Elevated opening pressure |
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What is the TX plan for Cryptococcosis?
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Cryptococcal meningitis is fatal if not treated
Treatment consists of 2 stages: induction (2 weeks) and consolidation (8 weeks or until CSF cultures are sterile) This is followed by chronic maintenance therapy (lifelong, unless immune reconstitution on ART) |
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What do you use to TX cryptococcosis?
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Induction: amphotericin B + flucytosine , or liposomal amphotericin B + flucytosine
Consolidation: fluconazole Chronic maintenance: fluconazole |
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What is the lifelong TX used to suppress future occurrences of cryptococcosis?
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Fluconazole
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Caused by Histoplasma capsulatum
Endemic in midwest United States, Puerto Rico, some parts of Central America Occurs in 2-5% of AIDS patients in endemic areas who are not on ART In nonendemic areas, usually seen in those who previously lived in endemic area |
Histoplasmosis
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Acquired by inhalation
Reactivation of latent infection may occur Disseminated disease usually seen in patients with CD4 count <150 cells/µL Pulmonary histoplasmosis may occur with CD4 count >300 cells/µL Incidence has declined with use of potent ART |
Histoplasmosis
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What are the clinical manifestations of histoplasmosis?
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Disseminated multiorgan disease: fever, fatigue, weight loss
Respiratory symptoms in 50% Most common in patients with low CD4 count Isolated pulmonary disease: usually occurs in patients with higher CD4 count CNS, GI, and skin manifestations possible |
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How do you diagnose histoplasmosis?
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Detection of Histoplasma antigen in serum or urine
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Consider presumptive diagnosis of this if patient has disseminated histoplasmosis and CNS infection that is otherwise unexplained
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Histoplasma meningitis
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What is the TX plan (timeline) for histoplasmosis?
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Treatment consists of 2 stages: acute phase (3-10 days or until clinically improved) and consolidation (12 weeks)
This is followed by chronic maintenance therapy (lifelong) |
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What is the TX therapy for histoplasmosis?
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Severe disseminated
Acute phase: amphotericin B or liposomal amphotericin B IV Continuation phase: itraconazole for 12 weeks Less-severe disseminated Acute phase: itraconazole for 3 days Continuation phase: itraconazole for 12 weeks Meningitis Amphotericin B for 12-16 weeks, then maintenance |
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Caused by the T gondii, a protozoan
Disease usually caused by reactivation of latent tissue cysts Primary infection may be associated with acute cerebral or disseminated disease |
TOXOPLASMA GONDII ENCEPHALITIS
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Primary infection acquired from tissue cysts in undercooked meat or ingestion of sporulated oocysts (from cat feces) in soil, water, or food
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TOXOPLASMA GONDII ENCEPHALITIS
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What is the clinical manifestation of Toxoplasma Gondii Encephalitis?
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Focal encephalitis with headache, confusion, or motor weakness and fever
Focal neurological abnormalities, may progress to seizures, altered mental status, coma Dissemination may occur, with retinochoroiditis, pneumonia, other organ involvement |
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How do you diagnose Toxoplasma Gondii Encephalitis?
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Serum antitoxoplasma IgG (positive in almost all patients with TE)
IgM usually negative Definitive diagnosis: clinical syndrome + imaging + detection of organism (brain biopsy) |
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What is the preferred TX for Toxoplasma Gondii Encephalitis?
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Preferred:
Pyrimethamine + sulfadiazine + leucovorin Duration: ≥6 weeks, longer if extensive disease or incomplete response Lifelong chronic maintenance therapy (secondary prophylaxis) after completion of initial therapy, unless immune reconstitution on ART Preferred: TMP-SMX 1 DS PO QD |
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Member of the herpes virus family
Found in body fluids Blood, saliva, urine, breast milk Occurs in patients with advanced immunosuppression (CD4 count <50 cells/µL) Other risk factors: patient not on ART, previous opportunistic infections, high plasma HIV RNA (>100,000 copies/mL) Usually caused by reactivation of latent infection |
Cytomegalovirus CMV
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What are the five clinical manifestations of CMV?
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Retinitis
Colitis, cholangiopathy Esophagitis Pneumonitis Neurologic disease |
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Most common CMV end-organ disease
Usually unilateral, if untreated is likely to progress to involve both eyes Symptoms: if peripheral: floaters, scotomata, visual field defects, or may be asymptomatic |
Retinitis
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Examination: perivascular fluffy yellow-white retinal infiltrates, with or without hemorrhage
Progresses unless treated; may cause blindness |
Retinitis in CMV
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What specific tests are used to diagnose CMV?
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PCR, antigen assays, blood culture
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How are the five major clinical manifestations of CMV diagnosed?
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Retinitis: characteristic retinal changes on funduscopy
Colitis: mucosal ulcerations on endoscopy + biopsy with characteristic intranuclear and intracytoplasmic inclusions Esophagitis: ulceration of distal esophagus on endoscopy + biopsy with intranuclear inclusion bodies in endothelial cells Pneumonitis: interstitial infiltrates + multiple CMV inclusion bodies in lung tissue, and absence of other likely pathogens Neurologic disease: clinical syndrome + CMV in CSF or brain tissue; detection enhanced by PCR |
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How do you TX retinitis associated with CMV?
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Several effective treatments: oral valganciclovir, IV ganciclovir, IV ganciclovir followed by oral valganciclovir, IV foscarnet, IV cidofovir, ganciclovir intraocular implant + valganciclovir
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How do you tx sight-threatening lesions associated with CMV retinitis?
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Ganciclovir intraocular implant + oral valganciclovir (superior to IV ganciclovir for preventing relapse) or oral valganciclovir as below
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How do you tx peripheral lesions associated with CMV retinitis?
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no therapy clearly more effective; oral valganciclovir preferred because of ease of use
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How do you tx colitis/esophagitis associated with CMV?
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oral valganciclovir if adequate oral absorption for 21-28 days or until resolution of symptoms
Maintenance therapy usually not necessary; consider if relapse |
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How do you tx neurologic disease associated with CMV?
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Ganciclovir IV until symptoms improve
Maintenance therapy for life |
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This should be initiated in all patients with CMV retinitis, GI disease, or pneumonitis?
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Antiretroviral Therapy ART
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What is the preferred TX to prevent reoccurance of CMV?
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Preferred: valganciclovir 900 mg PO QD
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Associated with Kaposi sarcoma (all forms) and certain neoplastic disorders (multicentric Castleman disease, primary effusion lymphoma)
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HUMAN HERPESVIRUS-8 DISEASE
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This is usually seen in advanced immunosuppression (CD4 count <200 cells/µL), but can occur at any CD4 count
Pathogenesis unclear |
HHV-8 disease
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How do you diagnose Kaposi sarcoma?
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Biopsy
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How do you TX HHV-8 disease
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Limited studies
Consider potent ART for all who qualify Ganciclovir, foscarnet, cidofovir may regress lesions Consult with specialist |
