Transcript - Catalyst

HIV

Douglas Paauw, MD
A 25 yo man presents for evaluation of
fever, severe sore throat and headache.
On exam he has anterior and posterior
cervical as well as axillary adenopathy.
His rash is on the next slide
Which Clinical Feature Most
Suggests Acute HIV?
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Lymphadenopathy
Sore throat
Tonsilar exudate
Fever
Rash
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A)
Clinical Features of Primary
HIV-1 Infection
Fever (97%)
Lymphadenopathy (77%)
Pharyngitis (73%)
Maculopapular rash (70%)
Arthralgia/myalgia (58%)
Mucocutaneous ulceration (35%)
Diarrhea (33%)
Headache (30%)
Oral candidiasis (10%)
Diagnosis of Primary HIV
Infection
P24
Antigen
HIV RNA
Ann Intern Med 2001:134:25-29
Sens
88.7
100
Spec
100
97.4
Acute HIV Infection
Importance of diagnosing
Acutely
infected patients at high risk
for spreading disease
Option for early intervention
A 24 y.o. medical student sustains a needlestick. The
source patient is a 40 y.o. man with C3 HIV disease with
a viral load of 35,000. The needle used was an 18 gauge
needle used for a successful blood draw. What would you
recommend for the student?
1.
2.
3.
4.
Sequential HIV testing, no therapy
Zidovudine (AZT)
Zidovudine + 3TC (Combivir)
Zidovudine + 3TC + Nelfinavir
0% 0% 0% 0%
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Risk for HIV acquisition from
occupational injury
Hollow needle
 Deep injury
 Visible blood contamination
 Source patient with advanced HIV
 Source needle from artery/vein

HIV Postexposure Prophylaxis
Use three drugs (most common
regimen 2 NRT1 and a P1)
 Therapy for 4 weeks
 Lab eval for adverse effects at two
weeks
 No Neverapine!!

A 24 yo man with A2 HIV disease comes to
clinic to establish care. He has no
symptoms. His only exam finding is on the
next slide. He reports practicing safe sex
most of the time with several male sexual
partners
What is the Skin finding?
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Impetigo
Psoriasis
Eczema
Seborrheic dermatitis
Xerosis
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A)
What Tests do You Recommend?
A)
B)
C)
D)
E)
RPR, Hepatitis B serology, chest
Xray, CD4 count, viral load, CBC
CD4 count,viral load, CBC, BMP
CD4 count, viral load, Chest Xray,
Hep B serologies, lipids, toxo titers
CD4 count, viral load , lipids, BMP,
CBC, RPR, Hepatitis B serology,
toxo titers
CD4 count, viral load, toxo titers,
lipids
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Appropriate Tests For Initial
HIV Visit
T Cell subsets
 Viral load
 PPD
 RPR
 Hepatitis B*
 Toxo titers
 CBC,BMP,Lipids

HIV/RNA Levels
Risk for Progression
RNA level Progression (RR) Death (RR)
< 500
1.0
1.0
CD4 /yr
36
500-3,000
2.4
2.8
45
3,000-10,000
4.4
5.0
55
10,000-30,000
7.6
9.9
62
>30,000
13
18.5
76
HIV Disease
Immunizations
Pneumococcal vaccine
 Tetanus
 Hep B
 Influenza

A 43 y. o. man presents for evaluation. He was
diagnosed with HIV disease 2 months ago. He has a CD4
count of 190 and a viral load of 10,000. He has been
extremely compliant with all previous primary care visits
and has always taken medications without fail. What
would you recommend?
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4.
an
3.
o
2.
No antiretroviral therapy at this
time
Zidovudine (AZT)
Zidovudine + 3TC
Zidovudine + 3TC + Effavirenz
N
1.
HIV Interventions Based on
CD4 Count
CD4 Count
<500
<200
<200
< 50
Intervention
Antiretroviral therapy
Antiretroviral therapy
strongly recommended
PCP prophylaxis
MAC prophylaxis
Indications for Instituting
Antiretroviral Therapy





Motivated patient with history of adherence to followup appointments and medication regimens
Hepatitis B coinfected receiving hepatitis B therapy
Pregnant women
HIV nephropathy
Asymptomatic CD4< 500
Treat (especially if CD4<200)
A 37 y.o. man with C3 HIV returns for followup. He
reports feeling well. His last CD4 count was 400 and viral
load nondetectable 4 months ago. Meds: Tenofovir,
Atazanavir, Ritonavir, and 3TC. Labs are repeated today
and CD4 is 350 and viral load is 100,000. What do you
recommend.
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Heart-to-heart talk with the patient
Resistance testing
Switch from Atazanavir/Ritonivir to
Kaletra
Switch Tenofovir/3TC to DDI and
Effavirenz
Switch all his meds to new meds
H
1.
Medication adherence and
viral suppression
% of doses taken
> 95
90-95
85
% with viral load < 500
80
60
50
HIV and Increased Cancer Risk
Cancer
SRR
Anal
42.9
Vaginal
21.0
Hodgkin’s
14.7
Liver
7.7
Lung
3.3
Melanoma
2.6
Oropharyngeal
2.6
Leukemia
2.5
Colon
2.3
Renal
1.8
Annals of Int Med 2008;148:728-736.
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A 26 y.o. man with B2 HIV disease (CD4 count 222, viral
load 25,000) wishes to start antiretroviral therapy. He has
avoided therapy until now because he is bothered by the
large pill burden needed for antiretroviral therapy. What is
the fewest number of pills per day he could take to supply
triple therapy?
“Compact” Antiretroviral
Regimens

Atripla (Efavirenz/Tenofovir/Emtricitabine) 1 pill a day
 Efavirenz + Tenofovir + 3TC
Total 3 pills a day
 3TC + DDI+ Atazanavir
Total 4 pills a day
 Trizavir one tab twice a day

Combivir (AZT/3TC) + Efavirenz 1 combivir BID and one
efavirenz QHS
Total pills 3 per day
What Drugs Should Be Used?
A) PI + 2 NRTI’s (use
combination tabs)
B) Efavirenz + 2 NRTI’s
(use combination tabs)
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A 45 y.o. man with HIV disease presents with pain in his
lower extremities. He has a burning pain from the mid-calf
down his legs to the toes. He has a CD4 count of 190 and
a viral load of 1,000. His medications include: Zidovudine
(AZT), Didarosine (DDI), Nelfinavir, and Neveripine. What
is the most likely cause of his symptoms?
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3.
IV
2.
HIV Neuropathy
AZT
DDI
Nelfinavir
Neverapine
H
1.
Antiretroviral Therapy
Neuropathy
 ddC
 ddI
 d4T
Lipodystrophy Syndrome
Clinical Features
“Protease-paunch”
 Thin arms/legs
 Increased venous prominence
 Thin face
 Paronychia of great toes
 Buffalo hump

Hepatomegaly and Steatosis
Associated with Nucleoside Analogs



Estimated incidence 1.3/1000 p.y.
antiretroviral drug use
Frequently associated with metabolic acidosis
Believed to be caused by impairment of
mitochondrial RNA replication, disrupting
oxidation of FFA in the liver
Am J Gastroenterology 1995; 90(9):1433-6
What are the most common
physical findings in patients with
HIV?
A 39 y.o. man with C3 HIV disease presents for
evaluation of multiple lesions. These have been present
for several months. What is the most likely cause of these
lesions?
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HHV 8
Parvovirus
HSV 2
Bartonella Quintana
JC virus
H
1.
HIV Disease
Oral Ulcers
Differential Diagnosis
Apthous ulcer
Reaction to DDC
HSV
Histoplasmosis/Cryptococcosis
A 40 yo man with HIV disease presents
for evaluation. An abnormality (slide) is seen on
oral cavity exam. What is the cause of the
lesion?
What is the cause of the lesion?
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HHV 8
Parvovirus
Candida
Malignancy
EBV
H
1.
Oral hairy leukoplakia
Key points
 Usually
on the side of tongue
 Asymptomatic
 Does not scrape off
 Specific marker of HIV disease
 Etiology - EBV
Oral Candidiasis
Key points
Marker of immunodeficiency
(CD4 200-300)
 Three kinds of Candidiasis
– Erythematous, Pseudomembranous,
Angular chelitis
 Can scrape it off and KoH/culture for Dx
 Indication for PCP prophylaxis

Esophageal Symptoms in
Patients With HIV
If the patient has oral thrush and
esophageal symptoms, the positive
predictive value for esophageal
candidiasis is close to 100%
 Empiric treatment with fluconazole is
appropriate

A 30 y.o. male with C3 HIV disease (CD4 count 100)
presents with fevers, weight loss, and dry,
nonproductive cough. He has a history of PCP 1
year ago, occurring at a CD4 count of 150. He has a
history of IDU and is still using drugs. He has not
been taking his PCP prophylaxis (TMP/Sulfa)
regularly.
Physical exam - T - 39.5, p - 110, BP 100/60.
Cardiac - no murmurs.
Chest - clear.
Mouth - thrush present.
Lab - Hb 10, HCT 30, WBC 3.5, SGOT 20, SGPT 15,
LDH - 150.
Chest x-ray as shown.
What is the most likely diagnosis for this
patient?
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Pneumocstis Carinii
Mycobacterium avium
complex (MAC)
Non-Hodgkin’s
Lymphoma
Mycobacterium
Tuberculosis
Endocarditis
Pn
1.
Clinical manifestations of TB in
patients with advanced HIV
disease (CD4 < 200)
TB skin test usually negative.
 Physical exam - adenopathy common.
 Radiographs - hilar adenopathy
common. Middle, lower lobe infiltrates.
Cavitation uncommon.
 Extrapulmonary disease - > 50%.

Clinical Manifestations of Active TB
in Early vs. Late HIV Infections
Skin test
Adenopathy
Chest x-ray
Early
positive
unusual
upper lobe
Cavitation
common
Extrapulmonary 10 - 15%
Late
negative
common
lower lobe
adenopathy
rare
50%
What diagnosis does this patient have?
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Tuberculosis
Pneumocystis
Pneumocystis and
Pneumothorax
Pneumocystis and right
empyema
Septic pulmonary
embolus
Tu
1.
Pneumocystis Carinii Pneumonia
Indications for Steroids
 PO2
< 70 on RA
 A-a gradient > 35
 Dose: 40 mg po BID x 5d
40 mg po qd x 5d
20 mg po qd x 11d
PCP Prophylaxis
Indications (Any one)
CD4 count < 200 *
 History of oral candidiasis
 History of PCP

* May stop if on HAART > 6 months, with CD4
> 200 and viral suppression.
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A 21 yo man with HIV disease, CD4 count
550 and a negative viral load presents with
headaches. They have been present for
the past 4 months, occurring 5-6 times a
month, pain most intense behind his right
eye, headaches worse with exertion and
pounding in nature. Physical exam is
normal
What is the next step?
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co
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ra
B)
Non contrast CT scan
Contrast CT scan
MRI
Medication trial
No
n
A)
Head CT in patients with HIV
and headache

178 patients underwent 204 CT scans

Mass lesions present in 14/162 scans in
patients with CD4 counts < 200, No mass
lesions seen in 39 scans done in patients
with CD4 count > 200
AJNR 2000;21(3):451-454
A 38 y.o. female with C3 HIV disease (CD4 Ct
10) presents with fever and severe headache
for the past 48 hours. She has also had
increasing confusion over the past 4-5 days.
She has not had any seizures or focal
weakness. Past history of opportunistic
infections include an episode of PCP 6 months
ago.
Meds- Nelfinavir 1250mg BID, DDI 400 mg qd,
3TC 300mg daily, aerosolized pentamidine 300
mg q no.
Exam- T 101.5°, p 96
Neurological Exam- OX2 (does not know
place), nonfocal.
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What is the Most Appropriate Next
Step?
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Ce
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IV
B)
Begin IV Ceftriaxone
Lumbar Puncture
Begin IV Acyclovir
CT scan with contrast
Be
gin
A)
.
A 30 yo man with C3 HIV disease CD4 count 20, viral load
100,000 presents with headache and confusion. He has also had
nausea. On exam T39 he is oriented X2. Seb derm and OHL is
present. Lab- HG9 HCT 27 WBC 2,000. Head CT is normal. LPWBC 3, TP 150. What is the most likely Dx?
1.
2.
3.
4.
5.
Toxoplasmosis
CMV
HIV Encephalopathy
Cryptococcus
Cryptosporidia
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HIV Neurologic Disease
Low CD4 count (less than 100)
Cryptococcus
Toxoplasmosis
CNS Lymphoma
 NOT Cryptosporidia, CMV is rare
 HIV encephalopathy is not acute
