HIV and AIDS

elmhurst oraquick advance HIV 1/2 rapid test.

5 microliters blood or plasma or swab teeth/gums both upper and lower one time around (but not cheeks) push until hit bottom of vial

takes 20 minutes

if you use the loop, stir around in the vial

solution should appear pink

if from blood tube, can use lavendar (edta), green (sodium heparin), or sodium citrate (Light blue)

 

 

 

Elisa to elisa to western blot

New rapid test with 20 min turnaround:  OraQuick Rapid HIV by Abbott uses fingerstick blood.

MAI-gi c/o, biaxin, ribabutin, ethabutol.  Zithromax for prophylaxis

PCP-non-productive cough.  Prednisone 40 BID if PaO2<70 or Aa>35

Encephalitis-toxo, crypto (indolent course, do LP with pressures after CT on HIV CD4<200 c headache), HSV, lymphoma, PML

Esophagitis-candida, HSV, CMV

 

Acute HIV Presentation

Fever/Fatigue/Rash/Oral Ulcerations/Lymphadenopathy looks like mono

Quick and Dirty CD4 Count

A CD4 count less than 200/mm3 leads to more advanced disease. It is important to identify patients in this category, because they are at much higher risk of opportunistic infections, including Pneumocystis carinii pneumonia (PCP), tuberculosis (TB), toxoplasmosis, cryptosporidiosis, isosporiasis, esophageal candidiasis, cryptococcosis, and histoplasmosis. Disseminated Mycobacterium avium complex (MAC) or cytomegalovirus (CMV) infection tend to occur in patients with CD4 counts of less than 50/mm3

new study on cut-offs

<950 or >1700 for cut-offs for ALC for CD4<200 prediction

  • Blatt SP, Lucey CR, Butzin CA, Hendrix CW, and Lucey DR.  “Total lymphocyte count as a predictor of absolute CD4+ count and CD4+ percentage in HIV-infected persons.”  JAMA. 1993 Feb 3;269(5):622-6.
  • Crowe S, Turnbull S, Oelrichs R, and Dunne A.  “Monitoring of human immunodeficiency virus infection in resource-constrained countries.”  Clin Infect Dis. 2003 Jul 1;37(Suppl 1):S25-35.
  • Srirangaraj Sreenivasan and Venkatesha Dasegowda.  “Comparing Absolute Lymphocyte Count to Total Lymphocyte Count, as a CD4 T Cell Surrogate, to Initiate Antiretroviral Therapy.”  J Glob Infect Dis. 2011 Jul-Sep;3(3):265–268.
  • Srithanaviboonchai K, Rungruengthanakit K, Nouanthong P, Pata S, Sirisanthana T, and Kasinrerk W.  “Novel Low-Cost Assay for the Monitoring of CD4 Counts in HIV-Infected Individuals.”  JAIDS. 2008 Feb 1; 47(2):135-9
  • Academic Emergency Medicine Volume 18, Issue 4, pages 385–389, April 2011

 

HIV infection is a known risk factor for neuroleptic malignant syndrome and should be considered in any seropositive patient who takes an implicated antipsychotic medication, especially if they present with fever and some combination of cogwheeling, diaphoresis, disorientation, or rigidity.36 The antiretroviral drug abacavir (Ziagen) can cause a hypersensitivity reaction characterized by malaise, fever, and nausea, with or without vomiting. In such cases, the drug must be stopped and never restarted as fatal reactions may occur.

 

ALC = total white blood cell count X lymphocyte percentage

An ALC less than 1000 cells/mm3 was 91% predictive in identifying patients with CD4 counts less than 200 cells/mm3 (sensitivity only 67%, but specificity 96%), while an ALC greater than 2000 cells/mm3 was 95% predictive in identifying CD4 counts greater than 200 cells/mm3 (Ann Emerg Med 1998 32(3 Pt 1))

 

Prophylactic therapy with trimethoprim-sulfamethoxazole (TMP-SMX) or dapsone does not rule out PCP infection, as about one-fifth of compliant patients will suffer breakthrough infections. Nearly one-third of those using aerosolized pentamidine will also develop disease (NEJM 332(11))

 

About 35% of those with TB had no infiltrate, while 12% had a normal chest x-ray. (NEJM 340:5)

 

Resp

Although radiographic findings of many pulmonary complications may be nondiagnostic, certain patterns may be suggestive of specific disorders.  A focal infiltrate on plain chest radiography suggests bacterial pneumonia. A diffuse infiltrative process on chest radiography, especially in the absence of leukocytosis, is associated with PCP. PCP is suggested by increased serum LDH and hypoxia, which may be more severe than expected from radiographic findings. Hilar adenopathy with diffuse pulmonary infiltrates suggests cryptococcus, histoplasmosis, mycobacterial infection, or neoplasm. KS can exhibit cough, fever, and dyspnea, and the chest radiograph may mimic that seen with PCP.

PCP

See Fungal Infection Chapter

Eye

CMV retinitis occurs in 10% to 30% of HIV-infected patients, and is the most common cause of blindness in AIDS patients. With advances in HAART, reduced incidences of CMV retinitis have been observed, but discontinuation of HAART may result in intraocular inflammation.[i]  CMV retinitis typically produces severe necrotic vasculitis and retinitis. When present, it may be asymptomatic or may present as change in visual acuity, photophobia, scotoma, redness, or pain. It is diagnosed by its characteristic appearance on indirect ophthalmoscopy of fluffy white retinal lesions, often perivascular. Differential diagnosis includes toxoplasmosis, syphilis, HSV infection, VZV infection, and tuberculosis

CNS

Any HIV patient presenting with neuro complaints gets CT then an LP

Consider CT + and – or MRI c gadolinium

Serum vdrl, toxo serology, and crypto antigen

With LP, get VDRL, Crypto Antigen, Opening Pressures, TB, Use PCR if available for toxo, cmv, and EBV

Cryptococcus

May present as focal cerebral lesions of diffuse meningoencephalitis

The most common presenting symptoms are fever and headache, often accompanied by nausea and vomiting.  Less common are visual changes, dizziness, seizures and cranial nerve deficits.  The diagnosis depends on identifying organisms in CSF.  Cryptococcal antigen in the CSF is nearly 100% sensitive and specific; less definitive are India ink staining  (60-80% sensitive), fungal culture (95% sensitive) or serum cryptococcal antigen (95% sensitive).  Treatment of cryptococcal meningitis requires admission for IV amphotericin B (0.7 mg/kg/day); flucytosine (100 mg/kg/day) may be added to this regimen. A response can be expected approximately 60% of the time.

Toxoplasmosis

Toxoplasmosis tends to have a greater number of lesions with a predilection for the basal ganglia and corticomedullary area, versus lymphomas which are more often singular lesions located in the periventricular matter or corpus callosum.  Tuberculosis is characterized by an  inflammatory appearance on CT, with a thick isodense exudate filling the basal cisterns.     Patients with suspected toxoplasmosis should be admitted and treated with pyrimethamine (100-200 mg po loading dose, followed by 50-100 mg po/day), plus sulfadiazine (4-8 gm po/day) with folinic acid (10 mg po/day) to reduce the incidence of pancytopenia.  Short courses of high-dose steroids are beneficial in cases where significant edema or mass effect is noted; seizure prophylaxis with phenytoin, may also be used in these cases.

 

Differential of Masses on CT

with mass effect

toxo

primary lymphoma

tuberculoma

brain abscess

 

without mass effect

encephalopathy

HIV encephalopathy

GI

Patients with esophagitis usually complain of pain and difficulty swallowing. Candida albicans is most often responsible for esophagitis in AIDS patients, causing about 60%-75% of cases.119 Other etiologies include CMV and herpes simplex virus. The antiretroviral drug ddC can produce esophageal ulcers, and some patients with HIV have idiopathic esophageal ulcers that respond to steroids.120 Those using topical solutions for oral candidiasis, such as clotrimazole troches or nystatin suspensions, may not have visible evidence of oral or pharyngeal thrush but still have esophageal disease; topical solutions are effective for oral candidiasis but not for esophageal infection.

Diarrhea

Diarrhea is the most common gastrointestinal complaint in AIDS patients and is estimated to occur in 50% to 90%. Diarrhea can vary in severity from a few loose stools per day to massive fluid loss with prostration, fever, chills, and weight loss. Potential pathogens include parasites (Cryptosporidium parvum, Enterocytozoon bieneusi, Isospora belli, Giardia lamblia, Entameba histolytica, Microsporidia, Cyclospora, and others), bacteria (Salmonella, Shigella, Campylobacter, Helicobacter pylori, Mycobacterium tuberculosis, Mycobacterium avium complex, Clostridium difficile, and others), viruses (cytomegalovirus, herpes simplex, HIV, and others), and fungi (Histoplasma capsulatum, cryptococcus neoformans, coccidiodes imitis, and others). Significant gastrointestinal bleeding and dehydration have been associated with many pathogens, particularly CMV. Salmonella infection can be of particular concern in HIV-infected patients, often producing recurrent bacteremia and other significant clinical disease. Neoplastic GI involvement with KS or lymphoma may produce dysphagia, obstruction, intussusception, or diarrhea. Cryptosporidium and Isospora infections are commonly associated with HIV infection, and both organisms may produce prolonged watery diarrhea.[ii]112-113 Diagnosis may be sought using acid-fast staining of stool samples, or by monoclonal antibody, or enzyme-linked immunoabsorbent assays.  Treatment of these disorders is clinically variably successful.  Symptoms may be treated with diet modification or loperamide.  Cryptosporidium infections may be treated with some success with paromomycin (500 to 750 mg, PO, 4 times daily for 2 to 4 weeks), or azithromycin (2,400 mg/day on day 1, followed by 1,200 mg/day for 4 weeks, followed by 600 mg/day).[iii]114-115 Isospora infections are often successfully treated with TMP-SMX (1 DS tablet, PO, 3 times daily for 10 days, followed by twice weekly therapy for 3 weeks).[iv]1[v]16 Pyrimethamine or metronidazole may be used as alternative therapy.   ED management should include repletion of fluid and electrolytes and obtaining of appropriate diagnostic studies. These may include microscopic examination of stool for leukocytes and of stool samples for bacterial culture, acid-fast stain, ova, and parasites. If indicated, outpatient anoscopy, proctoscopy, or sigmoidoscopy (with or without biopsy) may be arranged for patients who require further evaluation but do not require immediate admission.  Management of symptoms of severe diarrhea not requiring specific therapy may include attapulgite (Kaopectate), psyllium (Metamucil), diet modification, or diphenoxylate hydrochloride with atropine (Lomotil).

Skin

Scabies

treat with 5% permethrin, single application

better yet Ivermectin 200 mcg/kg x 1 PO dose, as more effective and easier to take than lindane. (J Derm 28:481 2001)

 

Fever

PCP, pneumonia, MAC, lymphoma, toxo, line sepsis,

Send a cryptococcal antigen, blood cx for AFB, gallium scans or induced sputum for PCP

 

Lactic Acidosis

stavudine and didanosine when coadministered

didanosine and ribavarin coadministration

anecdotal reports of benefit from

thiamine 100 mg/day

riboflavin 50-200 mg/day

L-carnitine 990 mg tid

CoQ10 at least 50 mg/day

levels may be slow to normalize

 

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Warm Line National HIV consultation 8am-8pm (800-933-3413)

 

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