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HIV

roatf1 GI MED University Englisch 105 Karten

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  1. 1what are the causes of HIV?retrovirus
    HIV1 - most common
    HIV2 - similar poss longer latent period
  2. 2who gets HIV in UK?men more than women
    both gay/straight
    IVDU
    mother to baby
  3. 3immunology of HIV?binds CD4 receptors on helper T cells/ monocytes/macrophages/neural cells
    CD4 +ve cells go to the lymphoid tissue where virus replicates, release virions which infect new cells
    progression = depletion of CD4 cell function - depleted immune function
  4. 4virology of HIV?RNA retrovirus
    HIV1 + 2
    HIV1 has 9 subtypes
    enters cell - reverse transcritase makes DNA copy of RNA genome which is integrated into host DNA
    virions are released by budding
    number of circulating viruses eg viral load - predicts AIDS progression
  5. 5what are the stages of HIV?1. seroconversion
    2. asymptomatic infection
    3. persistent generalised LAD
    4. AIDS related complex
    5. AIDS
  6. 6seroconversion of HIV?ie 1y infection - can have transient illness 2-6 wks post exposure w:
    fever
    malaise
    myalgia
    pharyngitis
    macpap rash
  7. 7asymptomatic infection in HIV?what it sounds like but 30% have persistent generalised LAD -
    nodes >1cm at 2+ extrainguinal sites persisting 3 months +
  8. 8what is the AIDS related complex in HIV?later: constitutional sx: fever, night sweats, diarrhoea, wt loss, maybe minor opportunistic infections (candida, hairy leukoplakia, herpes zoster, recurrent herpes simplex, tinea etc)
  9. 9what is AIDS?HIV + an indicator dz
    CD4 <200
  10. 10indicator diseases for AIDS?pulm - PCP pneumonia, MAI, CMV, HHV-8, lymphoid interstitial pneumonitis
    GI - candidiasis (oral, oesophageal), anorexia, wt loss, viral hepatitis, sclerosing cholangitis, MAI, diarrhoea (bact, viral, protozoa), perianal dz (HSV, SCC), lymphoma.
    eyes- CMV retinitis
    CNS - meningoencephalitis, myelopathy, neuropathy, HAND, toxoplas, cryptococcus neoformans
  11. 11timescale for HIV?HIV -AIDS - 8yrs
    ARC- AIDS - 2yrs
    AIDS - death - 2yrs
    (without HARRT)
  12. 12what signs are best indicators of HIV progression?chronic fever
    PGL
    cough > 1 month
    chronic diarrhoea
    oral thrush
    wt loss > 10% one month
    TB
    zoster
  13. 13how is HIV diagnosed?serum HIV ab by ELISA - confirmed by western blot
    window period - in recent infection can be -ve (1-3 wks post exposure)
    window period - check HIV RNA/ core p24 ag or repeat ELISA at 6wks and 3 months can confirm dx
    rapid test kits - result in 30 mins , but need confirm w/ ELISA
    salivary tests available OTC in USA/UK - sens + spec
  14. 14what's good to know about HIV subtypes?A + B in UK
    D in africa
    hybrid - worse px, bind to immune cells more readily
  15. 15prevention measures for HIV?blood screening
    disposable equipment
    antenatal antivirals if HIV +ve +/- c section/bottle feeding
    patient education programme
  16. 16what is the strategy to stop HIV?good info
    accessible testing - opt out, not in
    condoms
    less simultaneous partners
    less alcohol to avoid risk taking
  17. 17circumcision + HIVprevents in 65%- also herpes
    but not reliable - don't act as if safe
  18. 18HIV + TB - nb to know?if HIV +ve and has fever, night sweats, wt loss then TB until prove otherwise - 90% sens
    beware MDR/ EDR TB
  19. 19mantoux test in HIV TB?can be -ve and presentation can be atypical
  20. 20latent TB in HIV?more reactivation, BCG does not prevent
  21. 21how to determine drug sensitivity in TB w/ HIVculture is vital
  22. 22presentation of TB HIV?CXR - normal or atypical - lobar/ bibasal pneumonia/ hilar LAD
    extrapulm + disseminated more common
  23. 23TB tx in poor countries + HIV?4 drug initial phase w/ rifampicin, isoniazid, pyrazinamide, ethambutol + 2 drug continuation phase - rif/ iso
    NB - w/ HIV there is increased TB cases and fatality after this regimen
  24. 24anti Tb + anti HIV drugs?increased tox (DV, hepatitis, rash, neuropathy) - can be best to delay HARRT until 1-2months after TB tx - unless CD4<100
  25. 25what is IRIS?immune reconstitution inflammatory response:
    HARRT reconstitutes CD4 counts - thus we get worsening of TB sx
  26. 26how to prevent MDR and XDR TB?DOTS - directly observed treatment strategy
    resp isolation of TB pts from HIV pts
  27. 271st line anti TB agents?iso
    rifampicin
    pyranizamide
    ehambutol
    streptomycin
    amikacin
    kanamycin
    capreomycin
  28. 282nd/3rd line TB drugs?ofloxacin
    moxifloxacin
    cycloserine
    ethionamide
    PAS
    clarithromycin
    azithromycin
    linezolid
    meropenem
    clavulanate
  29. 29what are the chief goals in reducing MDR TB?1. early isolation - suspicious CXR/ past MDR is enough
    2. DOTS
    3. staff isolation compliance
    4. ZN staining available 24/7 - do sputum in isolation rooms
    5. automatic closing doors on isolation rooms
    6. -ve air pressure
    7. only stop isolation after 3+ sputum samples AFB-ve on culture
    8. frequent tuberculin surveillance tests for workers and contacts
  30. 30what is XDR TBmost worrying strain
    poss no tx
    mostly russia and africa
    compulsory confinement
  31. 31what should all newly dx HIV patients have done?toxoplas
    CMV
    hep
    syph
  32. 32what is PCP?pneumonia
    life threatening fungal opportunistic infection HIV
  33. 33when to suspect PCP?HIV +ve
    cough
    breathless
    pneumothorax
    can have normal CXR
    CT shows changes
  34. 34what are the CT changes in PCP?diffuse ground glass opacity
    consolidation
    nodules
    cysts
  35. 35how is PCP diagnosed?sputum - induced or via bronchoscopy/ BAL
  36. 36tx PCP?high dose co trimoxazole (120mg/kg/day IVI 2-3wks) each dose preceded by prednisolone 50mg
  37. 37s/e of co-trimoxazole?nausea
    vomiting
    fever
    rash
    myelosuppression
  38. 38what is cotrimoxazole?1 part trimethoprim
    5 parts sulfamethoxazole
  39. 39what about 1y prophylaxis for PCP?if CD4 <200 the co-trimox 480mg/24hrs PO
    essential after 1st attack until CD4 >200
  40. 40what pathogens cause pulmonary infection in HIV?bact esp pneumococcal
    MAI
    CMV
    HHV-8 (kaposi's, lymphoma)
    lymphoid interstitial pneumonitis
  41. 41oral candida tx in HIV?nystatin oral suspension
  42. 42oesophageal candida sx + tx?sx - dysphagia
    retrosternal discomfort
    tx - fluconazole/ itraconazole PO 1-2 wks
    relapse common
  43. 43what other organisms can cause oral/oesophageal ulcers in HIV?HSV
    CMV
  44. 44what causes high LFTs and hepatomegaly in HIV?viral hep
    sclerosing cholangitis
    drugs
    MAI
  45. 45what are the symptoms of MAI infection?fever
    night sweats
    malaise
    anorexia
    wt loss
    abdo pain
    diarrhoea
    hepatomegaly
    anaemia
  46. 46how is MAI diagnosed?blood culture
    LN/ liver/ colon/ BM bx
  47. 47tx of MAI in HIV?ethambutol + clarithromycin + rifabutin
  48. 48what are the causes of chronic diarrhoea in HIv?bacteria - calmonella, shigella, campylobacter, mycobacteria, c diff
    protozoa - cryptosporidium, microsporidium
    viruses - CMV, adenovirus
  49. 49what are the causes of perianal dz in HIV?recurrent HSV ulceration
    perianal warts
    SCC
  50. 50what are the sx of CMV retinitis?loss of acuity, blindness
  51. 51fundoscopy of CMV retinitis?mozzarella pizza signs
  52. 52what is the tx for CMV retinitis?induction - ganciclovir eye implant
    valganciclovir PO 3 wks, then lower dose
    OR
    cidofovir
  53. 53what are the risks w/ ganciclovir eye implant for CMVR?can have post op retinal detachment
    no disease prevention in other eye
  54. 54what is HAND?chronic HIV associated neurocognitive disorder - dementia + various encephalopathies incl PML
  55. 55what is the main CNS pathogen in AIDS?toxoplasmosis gondii
  56. 56how does toxoplasmosis infect?via the gut - poorly cooked meat, soil-contaminated vegetables or via the lung/ broken skin
  57. 57what is the lifecycle of TG?cat is definitive host - ingests cysts
    passes oocysts in faeces - contaminate food/water/meat
    transmitted to humans - can go through placenta to baby
    in humans trophozoites are released from oocysts and migrate esp to brain, eye, muscle
    infection is lifelong and can be reactivated by HIV
  58. 58when to always suspect TG?undiagnosed LAD/ granulomatous uveitis/retinitis esp if immunosuppressed eg HIV, pregnant
  59. 59what is the clinical presentation of TG?mostly asx, in UK >50% infected by 70yrs
    if sx - resembles mono, self limiting (acquired)
    if congenital - eye infection - posterior uveitis in 2nd decade, can cause cataract
  60. 60what is the clinical presentation of TG in HIV pt?myocarditis
    encephalitis
    focal CNS signs
    stroke
    seizures
  61. 61how is TG diagnosed normally and in HIV?acute infxn - 4x rise in ab titre over 4 wks or specific IgM (unreliable if HIV)
    latent reactivation in HIV -need to look for TG antigen + IgG, poss PCR
    parasite isolation difficult- LN/CNS bx
  62. 62CT in TG?characteristic multiple ring enhancing lesions in CNS
  63. 63TG tx?not needed in mild
    for eye - pyrimethamine + sulfadiazine
    pregnant - get help - IgM fetal cord blood around 21 wks = severe infection
    add leucovorin (folinic acid)
  64. 64when is tx indicated in TG?typical CNS features, CD4<200
    +ve toxoplas IgG
    ring enhancing lesions CT MRI
  65. 65how long to tx TG in HIV?6 months
    and after - lifelong 2y prophylaxis - PCP prophylaxis also prevents TG
  66. 66what is cryptococcus neoformansyeast
    causes chronic meningitis (no neck stiffness)
    can cause pneumonia also
  67. 67what populations are likely to see cryptococcus neoformans?AIDS
    sarcoid
    hodgkins
    steroid tx
  68. 68what are the signs of cryptococcus neoformans?high ICP signs eg confusion, papilloedema, cranial nerve lesions
  69. 69how is cryptococcus neoformans dx?india ink stain CSF
    blood culture
    antigen detected in blood + CSF by latex agglutination
  70. 70what is the tx for cryptococcus neoformans?reduce ICP - repeat LPs, shunts
    amphotericin B + 5-flucytosine
  71. 712y prophylaxis in cryptococcus neoformans in HIV?fluconazole until CD4 >150 and antigen -Ve
  72. 72CNS tumours HIV?1y cerebral lymphoma
    B cell lymphoma
    NB distinguish from PML - CSF JCV PCR
  73. 73what is kaposi's sarcoma?spindle cell tumour caused by HHV8
  74. 74presentation kaposi's sarcoma?purple papules/ plaques on the skin+ mucosa of any organ
    mets to nodes
  75. 75types of kaposi's sarcoma?1 - classic - old jews/meds men
    2 - endemic - central africa
    in 1 + 2 - slow growing peripheral skin lesions, visceral involvement rare but can have in nodes + oedema
    3 - in IS eg organ transplant pt - aggressive tx - siromilus
    4 - AIDS related - can be life threatening with skin, gut, lung lesions - prevalence lowered w/ HARRT
  76. 76AIDS related KS presentation?lung - dyspnoea, haemoptysis
    bowel - nausea, abdo pain
  77. 77what are some rare sites for KS?CNS
    larynx
    eye
    glands
    heart
    breast
    wound
    bx sites
  78. 78dx KS?bx
  79. 79tx for KS?optimise HARRT +/- interferon a
    poss topical retinoids
    cryotherapy or readiotherapy for skin lesions
    chemo - peg liposomal doxorubicin +/- IL-2
  80. 80post needle stick procedure HIV +ve?encourage bleeding
    do not suck or use bleach
  81. 81how is post exposure prophylaxis admin-d?start ASAP duh
    continue for 28 days
    don't need if exposure more than 3 days ago
    regimen - 1 truvada, 2 kaletra
  82. 82what is truvada?tenofovir +
    emtricitabine
  83. 83what is kaletra?lopinavir + ritonavir
  84. 84what are the aims of HARRT?suppression HIV RNA conc in plasma below limit of detection
    part of holistic care plan - manage comorbidities, eg malnutrition, alcohol
  85. 85how is HIV monitored?CD4 count 3-6 months - expensive
    HIV RNA 3-6 months
    serum U+E, HCO3, Cl, creatinine, bilirubin, LFTs (6-12months)
    FBC differential 3-6 months
    fasting lipid profile + glucose annually
    pregnancy
    drug resistance
  86. 86when do we initiate HARRT?AIDS defining illness
    CD4<350
    regardless of CD4 in :
    pregnant, nephropathy, HBV
    or consider in high viral load or rapid CD4 decline
  87. 87what to consider before prescribing HARRT?drug interactions important so don't prescribe before confirming any drug interactions
    any new sign can be side effect or HIV dz
    know baseline viral load + CD4 count
    monitor - BP, U+E, glucose, lipids, WHY? because HARRT can cause insulin resistance/ renal failure
  88. 88what are the categories of drugs used in HARRT?NRTI - nucleoside reverse transcriptase inhibitors
    PIs - protease inhibitors
    NNRTIs - non NRTIs
    InSTIs - integrase strand transfer inhibitors
    CCR5 antagonists
  89. 89what are the NRTIs?zidovudine (AZT)
    didanosine (DDI, videx)
    lamivudine (3TC)
    Emtricitabine (FTC)
    stavudine (D4T)
    tenofovir
    abacavir
  90. 90zidovudine?1st anti_HIV drug
    s/e - anaemia, low WCC, GI disturbance, fever, rash, myalgia
    stop if: high LFTs, hepatomegaly, lactic acidosis
    c/i - anaemia, neutropenia, breastfeeding
  91. 91didanosine?need to hive GR >60 and wt <60
    s/e - pancreatitis, neutopathy, high urate, GI, retinal + optic nerve probs, liver failure
    stop if: raised LFTs, or amylase
    c/i - breastfeeding
  92. 92lamivudine?well tolerated
    take w/o food
    s/e - same as AZT but less common
    stop if: high LFTS, big liver, pancreatitis, lactic acidosis
  93. 93emtricatibine?like lamivudine but active against HBV
  94. 94stavudine?stop if neuropathy or high LFTs
  95. 95tenofovir?PO
    s/e same as lamivudine
  96. 96abacavir?po
    s/e - hepatitis, lactic acidosis, HS syndrome - rash, fever, vomiting (can be fatal if rechallanged)
  97. 97what do protease inhibs do?slow cell to cell spread
    lengthen time to 1st clinical event
    give w/ low dose ritonavir
    drug interactions - Cyt P450 system
    s/e - dyslipidaemia, hyperglycaemia, insulin resistance
  98. 98what are the PIs?lopinavir/ritonavir (kaletra)
    s/e - as for saquinavir
  99. 99what are the NNTRIs?nevirapine
    efavirenz
    rilpiravine
  100. 100nevirapine?resistance
    s/e - stevens johnson syndrome, toxic epidermal necrolysis, hepatitis
  101. 101efavirenz?s/e - rash insomnia dizzy
    not in pregnancy
  102. 102what are the InSTIs?the -egravirs
    combo w/ tenofovir lamiduvine
    se - GI upset, insomnia
  103. 103what are the once a day tablets in HIv tx?kivexa/epzicom - abacavir + lamivudine
    atripla -tenofovir, emtricitabine + efavirenz - se psych
    stribild
    eviplera
  104. 104what are the golden rules for HAART?start early before CD4<200
    strict adherance
    research trial?
    no more than 2 daily dosing if poss
    use > 3 drugs, no dual tx
    monitor
    change regimen if needed
    keep informed about research, new drugs
  105. 105what problem is emerging w/ HAART?resistance

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University GI MED Karteikarten am HIV, erstellt von roatf1 am 03/11/2014.
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