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54 Cards in this Set
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CD4 count where tuberculosis is most likely to manifest
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350
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CD4 count where oral candidaisis is most likely to manifest
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300-250
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CD4 count where cryptosporidiosis is most likely to manifest
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200
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CD4 count where kaposi's sarcoma is most likely to manifest
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350-200
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CD4 count where herpes simplex virus is most likely to manifest
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150-100
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CD4 count where PCP is most likely to manifest
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250-100
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CD4 count where MAC is most likely to manifest
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100-50
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CD4 count where toxoplasmosis is most likely to manifest
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100
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CD4 count where cryptococcus is most likely to manifest
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150-75
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CD4 count where esophageal candidaisis is most likely to manifest
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75
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CD4 count where CMV is most likely to manifest
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50
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clinical presentation sx of PCP (3)
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1. SOB
2. fever 3. nonproductive cough |
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physical findings of PCP (2)
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1. tachycardia
2. tachypnea |
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Lab findings for PCP (2)
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1. decreased PaO2 (impaired oxygenation)
2. increased lactic dehydrogenase (LDH--subtypes found in liver, muscle, lungs, and brain) |
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1. first line agent for PCP
2. Inhibits folic acid synthesis. 3. 19% get rash/fever 4. Other ADRs: neutropenia, thrombocytopenia, nausea, vomiting, hyperkalemia, and hepatitis 5. Rash: generally 8th to 12th day of therapy 6. Toxicity is due to sulfonamide component. 7. Mild symptoms may be managed by decreasing the dose or using antihistamines; however, sometimes require discontinuation of the drug. |
bactrim (TMP-SMX)
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dose for bactrim (TMP-SMX) in PCP
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**dose based on TMP component
15-20 mg/kg/day divided into TID or QID |
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PCP
Dapsone is a sulfone and may be used in patients who fail or are intolerant to SMX. What is the dose of TMP and dapsone for PCP? |
TMP 300 mg TID and dapsone 100 mg QD
Efficacy: > 80% 10% get rash/fever Other ADRs include methemoglobinemianausea, vomiting, and hemolysis (patients with glucose-6 phosphate dehydrogenase (G6PD) deficiency). |
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Second line regimen for PCP?
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Second-line regimen
1. Dose: Clindamycin 300 to 450 mg PO QID or 600 mg IV q 8 hrs plus Primaquine 15 mg PO QD. 2. Efficacy: > 80% 3. 21% get rash/fever 4. Fever, neutropenia, and methemoglobinemia occur in ~20% of patients and may necessitate discontinuation. 5. Primaquine may cause hemolysis in patients with G6PD deficiency. |
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trimetrexate used as second-line agent for PCP has what AE associated with it and what should be administered with it to prevent/reduce this event?
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bone marrow suppression
administer leucovorin 20 mg/m2 PO or IV qid (administer IV if single dose is >25 mg) **also rash and abnormal LFTs |
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PCP
1. first line agents (1) 2. second line agents (4) |
1. bactrim 15-20 mg/kg/day (TMP component) given TID-QID
2. second line clinda 300-450 QID + primaquine 15 mg QD pentamidine atovaquone trimetrexate |
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How long is active therapy continued for in patients with PCP?
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21 days
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When administering steroids (prednisone) to patients with PCP within the first 72 hours to reduce inflammatory effects what is the taper dose?
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40 mg BID on days 1-5
40 mg QD on days 6-10 20 mg QD on days 11-21 |
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what is the prophylaxis regimen for PCP?
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1. consider for patients---primary: CD4 <200; secondary: any patient with previous episode
2. TMP-SMX tx of choice regimens 1 tab TMP-SMX DS QD (preferred) 1 tab TMP-SMX SS QD (if difficult tolerating DS) 1 tab TMP-SMX DS 3x/week (not as effective) |
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when can prophylaxis for PCP be d/c
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when CD4 count greater than 200 for 3+ months
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how would a patient with TE (toxoplasmic encephalitis) present? (2_
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1. hemiparesis (weakness on one side of body)
2. abnormalities in speech |
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preferred tx for TE?
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1. sulfadiazine 1-1.5 g QID + pyrimethamine 200 mg x 1 then 75-100 mg QD (preferred)
**administer with leucovorin 10-20 mg QD **respond in 7-10 days but continued for 3-6 weeks following resolution of sx other 1. Clindamycin 600 mg QID plus pyrimethamine 200 mg x 1 then 75-100 mg QD 2. Pyrimethamine may also be combined with clarithromycin, azithromycin, atovaquone, or dapsone 3. TMP-SMX **Relapse ~100% once therapy is stopped |
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when to consider primary prophylaxis for TE
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when CD4 counts are 100 or less
use bactrim DS 1 QD is preferred |
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when to consider secondary prophylaxis for TE and what to use
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following treatment of active disease
use pyrimethamine 25-50 mg QD + sulfadiazine 500-1000 mg QID; leucovorin 10-25 mg QD |
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when to stop prophylaxis (primary and secondary) in TE
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1. Primary prophylaxis may be discontinued once CD4+ >200 cells/mm3 for 3-6 months.
2. Secondary prophylaxis should continue until: patient has completed initial therapy and patient is asymptomatic for toxoplasmosis 3. CD4+ >200 cells/mm3 for > 6 months 4. Secondary prophylaxis should be restarted if the CD4+ cells < 200 cells/mm3 |
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tx for cryptococal meningitis
1. preferred (1) |
1. Amphotericin B (0.7-1 mg/kg/day) + flucytosine (37.5 mg/kg PO QID) is the preferred regimen if severe infection is present.
2. Positive blood cultures 3. CSF antigen > 128:1 4. Positive CSF India ink 5 .Impaired mental status |
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tx for cryptococcal meningitis
1. alternative (1) |
Fluconazole 400-800 mg IV or PO QD plus flucytosine may be considered if unable to tolerate standard treatment
**continued for 8-10 weeks |
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for cryptococcal meningitis if flucytosine is used serum concentrations must remain below what to minimze hematologic adverse events
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100 mcg/ml
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cryptococcal meningitis prophylaxis
1. primary 2. secondary |
1. Secondary prophylaxis (maintenance therapy) with fluconazole (preferred) 200 mg QD or amphotericin B 0.6-1 mg/kg IV q.w. - t.i.w. recommended until: CD4+ count > 200 cells/mm3 for > 6 months
***Maintenance therapy should be restarted if CD4 decreaese below 200 cells/mm3 2. Primary prophylaxis is not recommended. |
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histoplasmosis primary prevention?
when to consider what to use |
Primary prophylaxis not generally used but may be considered if CD4 < 150 (Itraconazole 200 mg daily)
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clinical presentation of mycobacterium avium complex (10)
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common
1. Fever 2. night sweats 3. weight loss are common findings. frequently present 4. Diarrhea 5. malaise 6. anorexia also detected 7. Hepatomegaly 8. splenomegaly 9. lymphadenopathy Chest x-ray: Unremarkable 10. Laboratory findings: Non-specific, alkaline phosphatase may be elevated |
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anti-MAC therapy (3 components for induction therapy)
first line agents |
azithomycin (clarithromycin), ethambutol, rifabutin
1. Azithromycin--Dose: 600 mg PO QD; First-line agent; Toxicity: GI intolerance OR Clarithromycin--Dose: 500 mg PO BID; First-line agent; Toxicity: GI intolerance; Blood levels may be decreased with concomitant use of rifampin or rifabutin. 2. Ethambutol--Dose: 15-25 mg/kg (2.5 g max) PO QD; First-line agent; Toxicity: Optic neuritis; Second most active agent; Avoid use in young children 3. Rifabutin--Dose: 300 mg PO QD; First-line agent; Toxicities (hypersensitivity, GI intolerance, neutropenia, hepatotoxicity, fluid discoloration) |
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anti-MAC therapy
second- line agents (5) |
1. amikacin--Dose: 7.5-15 mg/kg/day IM or IV; Toxicities: Ototoxicity, nephrotoxicity
2. ciprofloxacin--Dose: 750 mg PO BID; Toxicities: GI and CNS intolerance; Drug interactions are common; Levofloxacin may be preferred 3. levofloxacin--Dose: 500 mg PO QD; Toxicities: GI and CNS intolerance 4. clofazimine--Dose: 100-200 mg PO QD; Toxicities: Dose-related skin discoloration and GI intolerance; May not be useful for pulmonary MAC 5. rifampin--Dose: 10 mg/kg (600 mg max) PO QD; Toxicities (hepatotoxicity, fluid discoloration, hypersensitivity) ; Drug interactions are common |
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anti-MAC therapy lifelng suppressive therapy is necessary unless: (3)
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1. asymptomatic for MAC
2. has completed 12 months of MAC therapy 3. CD4 count is greater than 100 for more than 6 months **restart prophylaxis if CD4 drops below 100 |
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secondary prophylaxis for MAC (2)
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Azithromycin 500 mg po qd plus ethambutol 15 mg/kg po qd
Clarithromycin 500 mg po bid plus ethambutol 15 mg/kg po qd |
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primary prophylaxis for MAC (2)
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Azithromycin (1,200 mg po weekly) or clarithromycin (500 mg po bid)
Alternative: rifabutin 300 mg po qd Recommended for patients with CD4+ < 50 cells/mm3 May discontinue if CD4+ > 100 cells/mm3 for 3-6 months |
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how could CMV present? (7)
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CMV may present as
1. Retinitis is the most common presentation (20-25%). 2. pneumonitis 3. hepatitis 4. GI ulcerations 5. encephalopathy 6. myeloradiculopathy 7. endocrine disorders. |
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Implantable ganciclovir-containing disk delivers_____ of drug over _____
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1-2 mcg/hr of drug over 6-7 months
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prophylaxis of CMV
1. primary 2. secondary |
1. Primary prophylaxis for CMV is not recommended.
2. Intraocular plus oral ganciclovir may also be used as suppressive therapy; Valganciclovir 900 mg po qd may also be used as suppressive therapy. |
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Immunocompromised patients require lifelong suppressive therapy for coccidiomycosis what is the drug used?
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fluconazole 400 mg QD
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therapy for coccidiomycosis (3)
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1. Amphotericin B 0.5-1 mg/kg/day IV for 7 days followed by 0.8 mg/kg IV QOD (preferred).
2. Fluconazole 400-800 mg PO QD. 3. Itraconazole 200 mg PO BID |
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_______as become a preferred agent for treatment of candidiasis in HIV/AIDS patients because of ease of administration and high rates of clinical cure.
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Fluconazole
May be treated with a variety of topical (e.g., nystatin or clotrimazole), oral (e.g., fluconazole, itraconazole, or ketoconazole), or intravenous (e.g., fluconazole or amphotericin B) therapies Repeated courses of fluconazole or prophylaxis with fluconazole may select for resistant Candida species. |
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KS: predicts mild course (10)
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Few lesions (less than 25)
Slow spread No visceral lesions No systemic symptoms No previous OI CD4+ 400+ cells/mm3 Normal ESR Undetectable p24 Normal beta-microglobulin Normal blood counts |
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KS: predicts aggressive course (10)
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Many lesions
Rapid spread Intraoral or GI lesions Systemic symptoms History of OIs CD4+ less than 200 ESR greater than 40 mm/hr Detectable p24 antigen beta-microglobulin greater than 5 Leukopenia or anemia |
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KS treatment:non-life threatening cases (1)
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Interferon-alpha-2a (INFalpha-2a)
Dose: 10-36 MU/day IV, IM, or SC followed by 36 MU three times weekly. Response 35-50% If pretreatment CD4+ greater than 200 cells/mm3, better response. toxicities: CNS, GI, rash, bone marrow suppression, and flu-like symptoms Response can be observed in 6-8 weeks; however, maximal response may take months. |
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KS treatment: life threatening (1 regimen-2 components)
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chemo with cytotoxic agents and radiation
cytotoxic agents: etoposide, vinblastine, vincristine, bleomycin, liposome-encapsulated doxorubicin, and liposome-encapsulated daunorubicin |
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treatment of mild lesions of HSV in HIV/AIDS (3)
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1. Acyclovir 400 mg PO three to five times daily.
2. Famciclovir 250 mg PO TID or 3. valacyclovir 1 g PO BID have also been studied. Treatment should continue until all lesions have completely crusted over. |
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treatment of severe HSV infections (perianal uclers, colitis, esophagitis, and pneumonia) in HIV/AIDS (3)
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1. Acyclovir 5 mg/kg IV Q8H (increase to 10 mg/kg if CNS involvement)
Acyclovir resistance suspected or persistent infection: 2. Foscarnet 40 mg/kg IV Q8H 3. Ganciclovir 5 mg/kg IV Q12H |
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suppressive therapy for HSV infections in HIV/AIDS (4)
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Acyclovir 400 mg PO PO BID or 200 mg TID
Foscarnet 40 mg/kg IV QD Famciclovir 250 mg PO BID Valacyclovir 500 mg PO QD |
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varicella zoster virus dermotomal infections usually resolve without therapy but if the lesions persist or become troublesome what therapy is used? (3)
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Acyclovir 800 mg PO five times daily
Famciclovir 500 mg PO TID Valacyclovir 1 g PO TID may also be used. |