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HIVKittima Rodgerd Rajavithi Hospital
Outline
HIV Pathophysiology Definition Epidemiology Clinical manifestation Oppurtunistic infection
Respiratory cardio Neurology Ophalmology
Oppurtunistic infection GI Renal Psychiatric
ARV Health care provider
Needle exposure
Today outline Monday outline
HIV
cytopathic retrovirus of the lentivirus family
Pathophysiology
two major subtypes of HIV, HIV-1 and HIV-2 HIV-2 causes a similar immune syndrome but is
restricted primarily to western Africa Transmission
Intercourse **semen, vaginal secretions direct inoculation into blood in cases of traumatic
tears in the mucosa infection of susceptible target cells Co – factor ** STD ( Treponema
pallidum,Haemophilus drcreyi ,HSV, Chalmydia trachomatis , Neisseria gonorrheae,Trichomonas vaginalis )
blood or blood products
Pathophysiology
Transmission• breast milk feeding and transplacental transmission in
utero zidovudine
second trimester through delivery and of the infant for 6 weeks
22.6% <5% Zidovudine and cesarean section delivery
Less than 1%
Epidemiology
HIV decline number in
Heterosexual group
Age > 13 year ( Definition )
Laboratory Diagnosis
Laboratory test
ELISA is approximately 99 percent specific and 98.5 percent sensitive
WB is nearly 100 sensitive and specific if performed under ideal laboratory conditions
Sensitivity of the various tests differs with stage of disease and test PCR greater than 99 % RNA or viral load 95 % viral culture and p24 antigen 95 -100 %
Case definition of AIDS
Age < 13 year
born to an HIV-infected mother and if the laboratory criterion or at least one of the other criteria is met.
Definitive Presumptive
• Positive 2 specimen -- HIV nucleic acid detection** -- p24 antigen test-- viral culture
• the criterion for definitively HIV infected is not met
• Positive 1 specimen
Clinical Manifestations
Acute HIV syndrome Asymtomatic Symtomatic HIV disease Cag III
progressive quantitative and qualitative deficiency of the subset of T lymphocytes
referred to as helper T cells (CD4+)
Acute HIV syndroms
acute HIV syndrome (fever, skin rash, pharyngitis, and myalgia)
occur less frequently in those infected by injection drug
use versus those infected by sexual contact. The syndrome is
typical of an acute viral syndrome and has been likened
to acute infectious mononucleosis
Acute HIV syndrome ( Sign and Symptom )
Primary HIV Infection A maculopapular rash is seen in over half of persons with symptomatic acute HIV infection. This less typical papular/vesicular rash was present in a patient with primary HIV infection. (Courtesy of Gregory K. Robbins, MD, MPH.)
Maculopapular rash
Clinical Pearl1.Consider acute HIV infection as a potential etiology in patients with aseptic meningitis, pharyngitis, or a maculopapular rash. 2 . Ensure proper follow-up
The Asymptomatic StageClinical Latency
the median time ~10 years The rate of disease progression is
directly correlated with HIV RNA levels Rate of decline of CD4+ >>> Symtomatic CD 4 + < 200
CD4+ and Oppertunistic infection
CD4CD 4 + ( cells /L )
infection management
> 500 same as normal host
200 – 500 Bacterial respiratory infection
<350/L ***ARV therapy
< 200 P.Jirovecii Prophylaxis P. jiroveci Trimethoprim/sulfamethoxazole (TMP/SMZ), 1 DS tablet qd PO
C. neoforman Fluconazole 200 mg/d PO
< 100 T. gondii TMP/SMZ 1 DS tablet PO qd
CMV Ganciclovir, 5–6 mg/kg 5–7 d/wk IVValganciclovir 900 mg bid POFoscarnet 90–120 (mg/kg)/d IV
< 50MACCMV
MAC Azithromycin 1200 mg weekly PO orClarithromycin 500 mg bid PO
Symtomatic HIV disease
Constitutional Symptoms and Febrile Illnesses fever in patients with later-stage HIV and AIDS CD 4 + HIV immune reconstitution illness by MAC most common noninfectious causes of fever are
neoplasm (NHL)and drug fever
Respiratory
most common community-acquired bacterial pneumonia
Pneumonia ( PORT can not use ) S. pneumoniae 6 time >> Sepsis
P.jiroveci Admission
new-onset pulmonary symptoms, especially those with hypoxia
CXR Pattern and DDx
Pattern DDx in HIV patientDiffuse interstitial infiltration
, CMV ,TB , Histoplasmosis , Coccidioidomycosis , MAI ,Lymphoid interstitial pneumonitis
Focal consolidation
Bacterial pneumonia , M. mycoplasma , P. jiroveci , MTB , MAI
Nodular lesion
TB ,Kaposi sarcoma , fungal , Toxoplasmosis , MAI
Cavity lesion P . Jiroveci , TB , Bacteria , Fungal
AdenopathyKaposi Sarcoma , TB , Lymphoma , Cryptococcosis
P. jirovecii
The classic presenting symptoms fever, cough (typically nonproductive), and
shortness of breath (progressing from being present only with exertion to being present at rest
CXR ** interstitial but negative 20% LDH elevation***low sensitivity and specificity Arterial blood gas analysis usually demonstrates
hypoxemia and an increase in the alveolar-arterial (A-a) gradient.
P. jirovecii
Definitive diagnosis organisms in lung
tissue The most ** open-lungtransbronchial biopsy bronchoscopy and
bronchoalveolar lavage revealing organisms on methenamine-silver stain
Clinical Pearls•Include PCP in the differential diagnosis of any HIV patient who presents with a persistent fever or respiratory complaint. •PCP can also affect the bone marrow, spleen, liver, GI tract, pancreas, palate, pericardium, thymus, central nervous system, or eyes
P. jirovecii
Initial therapy for PCP is TMP-SMX (TMP 15 mg/kg per d and SMX 75 mg/kg per d) either PO or IV for 3 weeks in two or three divided doses (typical oral dosage 2 DS tablets tid)
Adverse reactions (most commonly rash, fever, and neutropenia) occur in up to 65 percent of AIDS patients
with a PaO2 of less than 70 mm Hg or an alveolar-arterial gradient of greater than 35.29 oral prednisone 40 mg bid for 5 days, then 40 mg daily for 5 days, and then 20 mg daily for an additional 11 days
TB
200 to 500 times that in the general Clinical manifestations of TB in HIV infection vary severity of
immunosuppression CD4+ T-cell counts of 200 to 500 cells/ L
Classic manifestations cough with hemoptysis, night sweats, prolonged fevers, weight loss,
and anorexia ** RUL *** CD 4 + > 200 extrapulmonary manifestations are more common. Frequent sites of
dissemination are peripheral lymph nodes, bone marrow, and the urogenital system
Ichest x-ray may reveal diffuse or lower lobe bilateral reticulonodular infiltrates consistent with miliary spread, pleural effusions, and hilar and/or mediastinal adenopathy. 60–80% of patients have pulmonary disease 30–40% have extrapulmonary disease.
Definitive diagnosis stain culture of sputum Blood culture 15
% bronchoscopy with
biopsy high index of
suspicion
Other pulmonary
Baterial Streptococcus
pneumoniae, Haemophilus influenzae, Staphylococcus aureus. Productive cough,
leukocytosis, and the presence of a focal infiltrate
Fungal and other C. neoformans Aspergillus fumigatus. Kaposi sarcoma lymphocytic interstitial
pneumonitis CMV or MAC
CD4+ T-cell count drops below 50 cells/ L.
Cardiovascular
Cardiomyopathy Pericardial effusion infective endocarditis ( IVDU) CHF ,CAD, arrhythmia HIV-associated pulmonary hypertensionFollowing standard ED workup for these conditions,
consultation with a cardiologist and infectious disease specialist may be indicated.
CNS
90 percent of patients with AIDS 10 – 20 % presentation in ED
seizures, altered mental status, headache, meningismus, and focal neurologic deficits
The most common causes of neurologic symptoms include AIDS dementia, Toxoplasma gondii, and C.
neoformans
DDx
ED management
ED evaluation should complete neurologic examination
Worst headache First seizure Alteration of conscoius Change the quality
computed tomography (CT c contrast ) space-occupying lesions
lumbar puncture (LP) CSF studies that may be of value include opening and closing
pressures, cell count, glucose, protein, Gram stain, India ink stain, bacterial culture, viral culture, fungal culture, toxoplasmosis and cryptococcosis antigen, and coccidioidomycosis titer
ED management
Positive result >> admit Negative result
Admit to work up MRI
CT brain c contrast
Toxoplasma gondii Infection showing typical multiple ring-enhancing lesions seen in T.gondii (Courtesy of Edward C. Oldfield III, MD.)
TOXOPLASMA GONDII
less than 100 CD4 cells/ L headache, fever, focal neurologic deficits, altered
mental status, and seizures Ocular toxoplasmosis is a common complication of
HIV disease. Patients typically present with a visual disturbance such as decreased vision, floaters, or visual field deficits
TOXOPLASMA GONDII
CT brain Magnetic resonance
imaging (MRI)
Standard treatment pyrimethamine
100- to 200-mg load, then 50-100 mg per d)
sulfadiazine (4-8 g per d) folinic acid added (10 mg /d) .Steroids (Decadron 4 mg IV
q6h) beneficial for significant
edema or mass effect
DDX Management
Prophylaxis T. gondii
T cell counts <100/L and IgG antibody to Toxoplasma should receive primary prophylaxis for toxoplasmosis TMP/SMZ 1 DS tablet PO qd
Stop CD 4+ > 200 /L 6 month
AIDS DEMENTIA
HIV encephalopathy ( 10 to 15 percent )
progressive process commonly heralded by subtle impairment of recent memory and other cognitive deficits caused by direct HIV infection
obvious changes in mental status and more severe disturbances, including aphasia and motor abnormalities
AIDS DEMENTIA
CRYPTOCOCCOSIS
10 percent Cryptococcus neoformans CD4 cell counts are less than 50/ L most common presenting signs are fever and
headache, followed by nausea, altered mentation, and focal neurologic deficits. Presentation may be subtle, and meningismus is uncommon
CT brain - WNL
Skin
Diagnosis ***organisms in CSF
culture (95–100 percent sensitive) staining with India ink (60–80 percent sensitive) Serum cryptococcal antigen is also useful but has
slightly lower sensitivity (approximately 95 percent) LP ** Elevated intracranial pressure
Normal or modest elevations protein levels normal glucose or low glucose Cell ** < 20 cell opening pressure of greater than 25 cm H2O should prompt drainage of fluid until pressure is less than
20 cm H2O or 50 percent of opening pressure
Clinical Pearls 1. Perform the LP after the CT, and do so with the patient in a
lateral position so as to obtain a proper opening pressure. 2. Obtain a fourth tube of CSF for special studies such as
directogens (Haemophilus influenzaetype B, C. neoformans, Neisseria meningitides, Streptococcus pneumonia, Streptococcus agalactiae), acid-fast stains and cultures, VDRL, cytology, PCR (varicella zoster, enteroviruses, herpes simplex virus, parvovirus B19, JC 19 virus).
3. "False-positive" india ink stains can occur with other encapsulated organisms such as Klebsiella pneumoniae, Rhodotorula, Candida, and Proteus.
4. Blood cultures are positive in more than three-quarters of patients with cryptococcal meningitis.
ED management
Admit all case amphotericin B IV 0.7 mg/kg per d flucytosine 100 O mg/kg per d for 14 days followed by 8 to 10 weeks of oral fluconazole
Lifelong maintenance therapy with fluconazole (200 mg per d)
Seizure in HIV
DDx electrolyte imbalance
Opthalmologic
75% The most common ophthalmic finding in patients with
AIDS is retinal microvasculopathy retinal cotton-wool spots identical to be incidental
and do not cause visual disturbances The diagnostic dilemma is to distinguish these findings
from early CMV infection, and ophthalmologic consultation is recommended.
CMV retinitis
unilateral vision loss. If untreated, the condition progresses to bilateral blindness.
The funduscopic examination exudates hemorrhages Edema dense opaque lesions
"cottage cheese and ketchup" appearance
ED management
First-line treatment intraocular ganciclovir implant with oral ganciclovir
1.0 to 1.5 g PO tid alternative first-line therapy is ganciclovir 5 mg/kg IV
bid for 14 to 21 days. Visual loss and blindness occur in all cases without
early detection and prompt treatment. Even with treatment, there are frequent relapses and progression of disease, with 10 percent of affected patients ultimately going blind.
Herpes Zoster Othalmicus
Herpes Zoster Othalmicus
paresthesia and discomfort in the distribution of cranial nerve V1, followed by the appearance of the typical zoster skin rash.
Ocular complications include conjunctivitis, episcleritis, iritis, keratitis, secondary glaucoma, and rarely, retinitis
Preferred treatment is intravenous ayclovir (30–36 mg/kg per d) for at least 7 days. The role of maintenance therapy is unclear
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