Primary Care Exam 1 HIV

What is the highest demographic of people with HIV

males with male to male sexual contact, black ethnicity, 25-34 yrs old, in southern regions

What are the methods of exposure of HIV

Sexual contact, parenteral exposure, maternal transmission

What is the pathophys of HIV

it attaches to CD4 receptors on T lymphocytes, reverse transcriptase converts RNA to DNA, virus DNA is replicated, virions are made which then attach and spread to whole body. Cd4 cells are killed as virus spreads

What are the sx of a primary HIV infection

Flu like illness for 3-14 days 1-4 weeks after transmission

An asymptomatic HIV infection can last for how many years

up to 10

generalized lymphadenopathy, localized fungal infections of toes, fingernails, mouth, vagina. Oral hairy leukoplakia, widespread molluscum contagiosum and warts, exacerbations of psoriasis and seborrheic dermatitis, multidermal herpes zoster.

what are the sx of a symptomatic HIV infection

Pneumocystis jirovecii pneumonia, invasive fungal infections, mycobacterial infections, recurrent community acquired pneumonia, cytomegalovirus infection, enteric infections, CNS infections, malignancies (Kaposi sarcoma, non Hodgkin’s lymphoma, cervical dysplasia)

what opportunistic infections can occur with AIDS

HIV antibodies are produced in how long after transmission

6-8 weeks

How does an HIV antigen test help diagnose HIV

detects viral proteins 13-20 days after infection. Detect p24 antigen

How does an HIV antibody assay test help diagnose HIV

detects viral proteins and HIV 1 and 2 immunoglobulins. IgM 20 days after infection, IgG 30 days after.

How does a nucleic acid amplification test help diagnose HIV

detects HIV RNA in 6-8 days after infection. usually done if HIV exposure is too recent for the antigen and antibody assays to give a result

Ways to monitor HIV after diagnosis

CD4 and T lymphocyte counts (best indicator of disease progression), CD4+ percentage, Quantitative virology (shows if tx is effective by dec RNA), genotypic drug resistance assessment (helps pick the medicine to tx)

Ways to continually monitor HIV way after diagnosis

CBC (anemia, lymphopenia, thrombocytopenia), CMP (electrolytes, kidney func, liver func), STI testing, Hep B and C screening, Toxoplasmosis screening, TB screen, G6PD def, Chest x ray, Cytomegalovirus screen, HPV/pap screen, PID, cervical cancer

What is the goal of HIV tx

reduce and keep plasma HIV RNA low, the greater the HIV RNA is the greater the tx

what is the triple drug regimen of HIV tx

2 nucleoside reverse transcriptase inhibitors (NRTIs) + integrase strand transfer inhibitor (INSTI)

What does Nucleoside reverse transcriptase inhibitors (NRTI) medicine do for HIV

Blocks reverse trnascriptase

What are the side effects of NRTI med for HIV tx

dec bone density, bone marrow suppression, insulin resistance, dyslipidema, melanonychia, lipodystrophy

what are some medicines that are used to tx HIV

Abacavir, didanosine,

What do integrase strand transfer inhibitors do for HIV tx

Blocks HIV enzyme integrase

What are some HIV meds that are integrase strand transfer inhibitors

Bictegravir, cabotegravir,

What do nonnucleoside reverse transcriptase meds do to tx HIV

binds to and blocks reverse transcriptase.

What meds are consdiered nonnucleoside reverse transcriptase inhibitors for HIV tx

Delaviridine, doravirine, efavirenz,

what are protease inhibitors and how to they help tx HIV

they bind to and block reverse transcriptase.

what meds are protease inhibitors and can tx HIV

atazanivir, darunavir, fosamprenavir,

when does tx failure for HIV occur

when viral load is too high or doesn’t reduce enough, when CD4 cell counts dec a lot, or when the disease progresses. when the meds achieve theri 4 and 8 week goals but fail by 4-6 mo.

what are some reasons for HIV tx failure

resistance to antiretroviral agents, altered absorption or metabolism of meds, drug interactions, bad pt adherence

Pts with a CD4 count less than 200 cells/mm3 can get what opportunistic infection

Pneumocystis jirovecii pneumonia

fever, malaise, nonproductive cough/slight productive cough with white sputum, dyspnea, chest pain, spontaneous, pneumothorax. PE shows bilateral crackles and rhonchi, dec pulse ox <90

what are the signs and sx of opportunistic HIV infection pneumocystis jirovecii pneumonia

What workup can determine if a pt has Pneumocystis jirovecii pneumonia

Chest x ray shows dense diffuse bilateral perihilar infiltrates, CT of lungs shows diffuse groudn glass opacity, CBC shows mild leukocytosis, inc LDH, sputum culture, and bronchioalveolar lavage/tissue biopsy

What is the first line of study for confirmation of Pneumocystis jirovecii pneumonia in an HIV pt

sputum culture

What is tx for mild-moderate pneumocystis jirovecii pneumonia

Oral trimethoprim-sulfamethoxazole

What is tx for moderate-severe pneumocystis jirovecii pneumonia

IV trimethoprim-sulfamethoxazole or glucocorticoids

how to prophylax for Pneumocystis jirovecii pneumonia in HIV infection

Trimethoprim-sulfamethoxazole (TMS/TMP-SMX) or Dapsone. Pentamidine inhaler

in ohio and river valleys, CD4 <150. fever, weight loss over 1-2 mo, hemoptysis, chest pain, dyspnea, abdominal pain, diarrhea, hepatosplenomegaly, lymphadenopathy, maculopapular rash, skin/oral ulcers, meningitis

Signs and sx of Histoplasmosis

What workup do you order for Histoplasmosis, an HIV side infection

chest x ray shows difuse infiltrates and small nodules. Blood, bone marrow, tissue cultures, serum/urine antigen/antibody testing

How do you tx and prophylax Histoplasmosis

Amphotericin B and itraconazole for a yr. Prophylax with itraconazole 200 mg daily.

What is opportunistic infection from HIV Cryptosporidiosis

self limited to severe life threatening diarrheal illness. is psread fecal to oral, occurring in pts with CD4 ct <200 cells/mm3.

Weight loss, crampy abdominal pain, nausea, vomiting, diarrhea with frequent foul smelling bulky stool. can also be watery diarrhea. Also cholecystitis, sclerosing cholangitis, pancreatitis

Signs and sx of Cryptosporidiosis

What workup is needed to diagnose Cryptosporidiosis

stool testing and small intestine biopsy

How to tx Cryptosporidiosis

Supportive care with fluids, antimotility agents, nutrition. Nitazoxanide improves sx and dec viral shedding but isn’t to cure. Parasite can only be gone when CD4 ct is nl

What is opportunistic HIV infection Mycobacterium avium complex

disseminated nonTB infection, occurs in pts with CD4 of <50 cells/mm3.

fever, weight loss, night sweats, abdominal pain, diarrhea. PE shows wasting, skin pallor, lymphadenopathy, tender hepatosplenomegaly

What are signs and sx of Mycobacterium avium complex

What workup is needed to diagnose Mycobacterium avium complex

Blood cultures, aspirate from lymph nodes or bone marrow, chest x ray shows bilateral lower lobe infiltrates and hilar/mediastinal lymphadenopathy

how to tx mycobacterium avium complex

macrolide antibiotic (azithromycin or clarithromycin) + ethambutol + rifabutin or ciprofloxacin or amikacin as third agent

How to prophylax for Mycobacterium avium complex

When your CD4 ct is <50 cells/mm3 and you aren’t starting antiretrovirals then you take Clarithromycin 500mg or azithromycin 1200 mg once weekly.

What is opportunistic HIV infection toxoplasmosis

In pts with CD4 ct <100-200 cells/mm3.

fever, headache, focal neurological deficits (seizures, hemiparesis (one side body weak), aphagia (no swallow), confusion/AMS, dementia, coma

Signs and sx of Toxoplasmosis

what workup is needed to diagnose Toxoplasmosis

Toxoplasmosis IgM/IgG, CT brain scan showing multiple ring enhancing lesions, brain biopsy

What is characteristic of CT brain scan that shows Toxoplasmosis

Multiple ring enhancing lesions

How to tx toxoplasmosis

Sulfadiazine + pyrimethamine + leucovorin for 6 weeks. don’t touch raw meat or soil

How to prophylax for Toxoplasmosis

When your CD4 is <100 . TMS single strength once daily or TMS DS one tablet 3 times a week. If TMS isn’t possible then dapsone + pyrimethamine + folinic acid

CD4 count <100-300 cells/mm3. what opportunistic infection

What is opportunistic HIV infection Candidiasis

creamy white exudate on erythematous mucosa on or in buccal mucosa, gingiva, tongue, posterior pharynx, or esophagus. Can be scraped off. Dysphagia, retrosternal burning, odynophagia

Signs and sx of Candidiasis

What workup is needed to diagnose Candidiasis

Scraping exudate, endoscopy

How to tx Candidiasis

Oropharyngeal luconazole 200 mg on day 1.then nystatin. Esophageal tx is fluconazole, then Itraconazole, then Capsofungin

What is opportunistic HIV infection CMV (cytomegalovirus)

CD4 ct < 100 cells/mm3. High risk of getting CMV retinitis when CD4 <50. Irreversible vision loss

If I have CMV what other infection am I at risk of and what can happen?

I can get CMV retinitis and get irreversible vision loss

Signs and sx of CMV retinitis

painless proressive bilateral vision loss, blurred vision, floaters, scintillations, perivascular hemorrhage and exudate seen on ophthalmologic examination

How to tx CMV

Valganciclovir, ganciclovie, or foscarnet

What is a malignancy that can occur with HIV

Kaposi sarcoma (human herpes virus 8)

What is Kaposi carcoma

Neoplasm seen at any stage of HIV infection. Progresses over 10-15 yrs with slow enlargement of lesions and creation of more lesions. Multiple vascular nodules appearing on skin, mucosa, and viscera.

Lymphedema, odynophagia, dysphagia, nausea, vomiting, abdominal pain, hematemesis, hematochezia, cough, dyspnea, hemoptysis, lymphadenopathy

Signs and sx of kaposi sarcoma

How to describe the lesions of kaposi sarcoma

localized to lower extremities, head, neck. macular or papular, nodular or plaque like appearance. Brown, pink, red, or violaceous in color. Non pruritic (not itchy).

What workup do you need to diagnose kaposi sarcoma

HIV testing if status is not known, CD4 lymphocyte ct, biopsy of lesion

How to tx kaposi sarcoma

optimal control or HIV with antiretroviral, localized radiation if lesions are uncomfortable, chemotherapy if large # of lesions or in pts with viscera involved.