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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