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  1. 1. HIV Kittima Rodgerd Rajavithi Hospital
  2. 2. Outline <ul><li>HIV </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Definition </li></ul><ul><li>Epidemiology </li></ul><ul><li>Clinical manifestation </li></ul><ul><li>Oppurtunistic infection </li></ul><ul><ul><li>Respiratory </li></ul></ul><ul><ul><li>cardio </li></ul></ul><ul><ul><li>Neurology </li></ul></ul><ul><ul><li>Ophalmology </li></ul></ul><ul><li>Oppurtunistic infection </li></ul><ul><ul><li>GI </li></ul></ul><ul><ul><li>Renal </li></ul></ul><ul><ul><li>Psychiatric </li></ul></ul><ul><li>ARV </li></ul><ul><li>Health care provider </li></ul><ul><ul><li>Needle exposure </li></ul></ul><ul><li>Today outline </li></ul><ul><li>Monday outline </li></ul>
  3. 3. HIV cytopathic retrovirus of the lentivirus family
  4. 4. Pathophysiology <ul><li>two major subtypes of HIV, HIV-1 and HIV-2 </li></ul><ul><li>HIV-2 causes a similar immune syndrome but is restricted primarily to western Africa </li></ul><ul><li>Transmission </li></ul><ul><ul><li>Intercourse ** semen, vaginal secretions </li></ul></ul><ul><ul><ul><li>direct inoculation into blood in cases of traumatic tears in the mucosa </li></ul></ul></ul><ul><ul><ul><li>infection of susceptible target cells </li></ul></ul></ul><ul><ul><ul><li>Co – factor ** STD ( Treponema pallidum,Haemophilus drcreyi ,HSV, Chalmydia trachomatis , Neisseria gonorrheae,Trichomonas vaginalis ) </li></ul></ul></ul><ul><ul><li>blood or blood products </li></ul></ul>
  5. 5. Pathophysiology <ul><ul><li>Transmission </li></ul></ul><ul><ul><li>breast milk feeding and transplacental transmission in utero </li></ul></ul><ul><ul><li>zidovudine </li></ul></ul><ul><ul><ul><li>second trimester through delivery and of the infant for 6 weeks </li></ul></ul></ul><ul><ul><ul><li>22.6% <5% </li></ul></ul></ul><ul><ul><li>Zidovudine and cesarean section delivery </li></ul></ul><ul><ul><ul><li>Less than 1% </li></ul></ul></ul>
  6. 6. Epidemiology HIV decline number in Heterosexual group
  7. 7. Age > 13 year ( Definition )
  8. 8. Laboratory Diagnosis
  9. 9. Laboratory test <ul><li>ELISA is approximately 99 percent specific and 98.5 percent sensitive </li></ul><ul><li>WB is nearly 100 sensitive and specific if performed under ideal laboratory conditions </li></ul><ul><li>Sensitivity of the various tests differs with stage of disease and test </li></ul><ul><ul><li>PCR greater than 99 % </li></ul></ul><ul><ul><li>RNA or viral load 95 % </li></ul></ul><ul><ul><li>viral culture and p24 antigen 95 - 100 % </li></ul></ul>
  10. 10. Case definition of AIDS
  11. 11. Age < 13 year <ul><li>born to an HIV-infected mother and if the laboratory criterion or at least one of the other criteria is met. </li></ul>Definitive Presumptive <ul><li>Positive 2 specimen -- HIV nucleic acid detection** -- p24 antigen test -- viral culture </li></ul><ul><li>the criterion for definitively HIV infected is not met </li></ul><ul><li>Positive 1 specimen </li></ul>
  12. 12. Clinical Manifestations <ul><li>Acute HIV syndrome </li></ul><ul><li>Asymtomatic </li></ul><ul><li>Symtomatic HIV disease Cag III </li></ul>
  13. 13. progressive quantitative and qualitative deficiency of the subset of T lymphocytes referred to as helper T cells (CD4+)
  14. 14. 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
  15. 15. Acute HIV syndrome ( Sign and Symptom )
  16. 16. 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 <ul><li>Clinical Pearl </li></ul><ul><li>Consider acute HIV infection </li></ul><ul><li>as a potential etiology in patients </li></ul><ul><li>with aseptic meningitis, </li></ul><ul><li>pharyngitis, or a maculopapular rash. </li></ul><ul><li>2 . Ensure proper follow-up </li></ul>
  17. 17. The Asymptomatic Stage Clinical Latency <ul><li>the median time ~10 years </li></ul><ul><li>The rate of disease progression is directly correlated with </li></ul><ul><ul><li>HIV RNA levels </li></ul></ul><ul><ul><li>Rate of decline of CD4+ </li></ul></ul><ul><ul><li>>>> Symtomatic CD 4 + < 200 </li></ul></ul>
  18. 18. CD4+ and Oppertunistic infection
  19. 19. CD4 decline in CD4+ T cell count of >25% *** change the ARV CD 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 IV Valganciclovir 900 mg bid PO Foscarnet 90–120 (mg/kg)/d IV < 50 MAC CMV MAC Azithromycin 1200 mg weekly PO or Clarithromycin 500 mg bid PO
  20. 20. Symtomatic HIV disease <ul><li>Constitutional Symptoms and Febrile Illnesses </li></ul><ul><li>fever in patients with later-stage HIV and AIDS </li></ul><ul><li>CD 4 + </li></ul><ul><li>HIV </li></ul><ul><li>immune reconstitution illness by MAC </li></ul><ul><li>most common noninfectious causes of fever are neoplasm (NHL) and drug fever </li></ul>
  21. 21. Respiratory <ul><li>most common </li></ul><ul><ul><li>community-acquired bacterial pneumonia </li></ul></ul><ul><ul><ul><li>Pneumonia ( PORT can not use ) </li></ul></ul></ul><ul><ul><ul><li>S. pneumoniae 6 time >> Sepsis </li></ul></ul></ul><ul><ul><li>P.jiroveci </li></ul></ul><ul><li>Admission </li></ul><ul><ul><li>new-onset pulmonary symptoms, especially those with hypoxia </li></ul></ul>
  22. 22. CXR Pattern and DDx Pattern DDx in HIV patient Diffuse 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 Adenopathy Kaposi Sarcoma , TB , Lymphoma , Cryptococcosis
  23. 23. P. jirovecii <ul><li>The classic presenting symptoms </li></ul><ul><li>fever, cough (typically nonproductive), and shortness of breath (progressing from being present only with exertion to being present at rest </li></ul><ul><li>CXR ** interstitial but negative 20% </li></ul><ul><li>LDH elevation*** low sensitivity and specificity </li></ul><ul><li>Arterial blood gas analysis usually demonstrates hypoxemia and an increase in the alveolar-arterial (A-a) gradient. </li></ul>
  24. 24. P. jirovecii <ul><li>Definitive diagnosis </li></ul><ul><li>o rganisms in lung tissue </li></ul><ul><ul><li>The most ** open-lung </li></ul></ul><ul><ul><li>transbronchial biopsy </li></ul></ul><ul><ul><li>bronchoscopy and bronchoalveolar lavage revealing organisms on methenamine-silver stain </li></ul></ul><ul><li>Clinical Pearls </li></ul><ul><li>Include PCP in the differential diagnosis of </li></ul><ul><li>any HIV patient who presents with a persistent fever </li></ul><ul><li>or respiratory complaint. </li></ul><ul><li>PCP can also affect the bone marrow, spleen, liver, GI tract, pancreas, palate, </li></ul><ul><li>pericardium, thymus, central nervous system, or eyes </li></ul>
  25. 25. P. jirovecii <ul><li>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) </li></ul><ul><li>Adverse reactions (most commonly rash, fever, and neutropenia) occur in up to 65 percent of AIDS patients </li></ul><ul><li>with a PaO 2 of less than 70 mm Hg or an alveolar-arterial gradient of greater than 35.29 </li></ul><ul><ul><li>oral prednisone 40 mg bid for 5 days, </li></ul></ul><ul><ul><li>then 40 mg daily for 5 days, </li></ul></ul><ul><ul><li>and then 20 mg daily for an additional 11 days </li></ul></ul>
  26. 26. TB <ul><li>200 to 500 times that in the general </li></ul><ul><li>Clinical manifestations of TB in HIV infection vary severity of immunosuppression </li></ul><ul><ul><li>CD4 + T-cell counts of 200 to 500 cells/ L </li></ul></ul><ul><li>Classic manifestations </li></ul><ul><ul><li>cough with hemoptysis, night sweats, prolonged fevers, weight loss, and anorexia ** RUL *** CD 4 + > 200 </li></ul></ul><ul><ul><li>extrapulmonary manifestations are more common. Frequent sites of dissemination are peripheral lymph nodes, bone marrow, and the urogenital system </li></ul></ul><ul><ul><li>Ichest x-ray may reveal diffuse or lower lobe bilateral reticulonodular infiltrates consistent with miliary spread, pleural effusions, and hilar and/or mediastinal adenopathy. </li></ul></ul><ul><ul><ul><li>60–80% of patients have pulmonary disease </li></ul></ul></ul><ul><ul><ul><li>30–40% have extrapulmonary disease. </li></ul></ul></ul>
  27. 27. <ul><li>Definitive diagnosis </li></ul><ul><ul><li>stain </li></ul></ul><ul><ul><li>culture of sputum </li></ul></ul><ul><ul><li>Blood culture 15 % </li></ul></ul><ul><ul><li>bronchoscopy with biopsy </li></ul></ul><ul><li>high index of suspicion </li></ul>
  28. 28. Other pulmonary <ul><li>Baterial </li></ul><ul><ul><li>Streptococcus pneumoniae, </li></ul></ul><ul><ul><li>Haemophilus influenzae, </li></ul></ul><ul><ul><li>Staphylococcus aureus. </li></ul></ul><ul><ul><li>Productive cough, leukocytosis, and the presence of a focal infiltrate </li></ul></ul><ul><li>Fungal and other </li></ul><ul><li>C. neoformans </li></ul><ul><li>Aspergillus fumigatus. </li></ul><ul><li>Kaposi sarcoma </li></ul><ul><li>lymphocytic interstitial pneumonitis </li></ul><ul><li>CMV or MAC </li></ul><ul><ul><li>CD4 + T-cell count drops below 50 cells/ L. </li></ul></ul>
  29. 29. Cardiovascular <ul><li>Cardiomyopathy </li></ul><ul><li>Pericardial effusion </li></ul><ul><li>infective endocarditis ( IVDU) </li></ul><ul><li>CHF , CAD, arrhythmia </li></ul><ul><li>HIV-associated pulmonary hypertension </li></ul><ul><li>Following standard ED workup for these conditions, consultation with a cardiologist and infectious disease specialist may be indicated. </li></ul>
  30. 30. CNS <ul><li>90 percent of patients with AIDS </li></ul><ul><li>10 – 20 % presentation in ED </li></ul><ul><ul><li>seizures, altered mental status, headache, meningismus, and focal neurologic deficits </li></ul></ul><ul><li>The most common causes of neurologic symptoms include </li></ul><ul><ul><li>AIDS dementia, Toxoplasma gondii, and C. neoformans </li></ul></ul>
  31. 31. DDx
  32. 32. ED management <ul><li>ED evaluation should </li></ul><ul><ul><li>complete neurologic examination </li></ul></ul><ul><ul><ul><li>Worst headache </li></ul></ul></ul><ul><ul><ul><li>First seizure </li></ul></ul></ul><ul><ul><ul><li>Alteration of conscoius </li></ul></ul></ul><ul><ul><ul><li>Change the quality </li></ul></ul></ul><ul><ul><li>computed tomography (CT c contrast ) space-occupying lesions </li></ul></ul><ul><ul><li>lumbar puncture (LP) </li></ul></ul><ul><ul><ul><li>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 </li></ul></ul></ul>
  33. 33. ED management <ul><li>Positive result >> admit </li></ul><ul><li>Negative result </li></ul><ul><ul><li>Admit to work up </li></ul></ul><ul><ul><li>MRI </li></ul></ul>
  34. 34. CT brain c contrast Toxoplasma gondii Infection showing typical multiple ring-enhancing lesions seen in T.gondii (Courtesy of Edward C. Oldfield III, MD.)
  35. 35. T OXOPLASMA GONDII <ul><li>less than 100 CD4 cells/ L </li></ul><ul><li>headache, fever, focal neurologic deficits, altered mental status, and seizures </li></ul><ul><li>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 </li></ul>
  36. 36. T OXOPLASMA GONDII <ul><li>CT brain </li></ul><ul><li>Magnetic resonance imaging (MRI) </li></ul><ul><li>Standard treatment </li></ul><ul><li>pyrimethamine </li></ul><ul><ul><li>100- to 200-mg load, then 50-100 mg per d) </li></ul></ul><ul><li>sulfadiazine (4-8 g per d) </li></ul><ul><li>folinic acid added (10 mg /d) </li></ul><ul><li>.Steroids (Decadron 4 mg IV q6h) </li></ul><ul><ul><li>beneficial for significant edema or mass effect </li></ul></ul><ul><li>DDX </li></ul><ul><li>Management </li></ul>
  37. 37. Prophylaxis T. gondii <ul><li>T cell counts <100/L and IgG antibody to Toxoplasma should receive primary prophylaxis for toxoplasmosis </li></ul><ul><ul><li>TMP/SMZ 1 DS tablet PO qd </li></ul></ul><ul><li>Stop CD 4+ > 200 /L 6 month </li></ul>
  38. 38. AIDS DEMENTIA <ul><li>HIV encephalopathy ( 10 to 15 percent ) </li></ul><ul><ul><li>progressive process commonly heralded by subtle impairment of recent memory and other cognitive deficits caused by direct HIV infection </li></ul></ul><ul><ul><li>obvious changes in mental status and more severe disturbances, including aphasia and motor abnormalities </li></ul></ul>
  40. 40. CRYPTOCOCCOSIS <ul><li>10 percent </li></ul><ul><li>Cryptococcus neoformans </li></ul><ul><li>CD4 cell counts are less than 50/ L </li></ul><ul><li>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 </li></ul><ul><li>CT brain - WNL </li></ul>
  41. 41. Skin
  42. 42. Diagnosis *** organisms in CSF <ul><ul><li>culture (95–100 percent sensitive) </li></ul></ul><ul><ul><li>staining with India ink (60–80 percent sensitive) </li></ul></ul><ul><ul><li>Serum cryptococcal antigen is also useful but has slightly lower sensitivity (approximately 95 percent) </li></ul></ul><ul><ul><li>LP ** Elevated intracranial pressure </li></ul></ul><ul><ul><ul><li>Normal or modest elevations protein levels </li></ul></ul></ul><ul><ul><ul><li>normal glucose or low glucose </li></ul></ul></ul><ul><ul><ul><li>Cell ** < 20 cell </li></ul></ul></ul><ul><ul><ul><li>opening pressure of greater than 25 cm H 2 O </li></ul></ul></ul><ul><ul><ul><li>should prompt drainage of fluid until pressure is less than 20 cm H 2 O or 50 percent of opening pressure </li></ul></ul></ul>
  43. 43. Clinical Pearls <ul><li>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. </li></ul><ul><li>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). </li></ul><ul><li>3. &quot;False-positive&quot; india ink stains can occur with other encapsulated organisms such as Klebsiella pneumoniae, Rhodotorula, Candida, and Proteus. </li></ul><ul><li>4. Blood cultures are positive in more than three-quarters of patients with cryptococcal meningitis. </li></ul>
  44. 44. ED management <ul><li>A dmit all case </li></ul><ul><ul><li>amphotericin B IV 0.7 mg/kg per d </li></ul></ul><ul><ul><li>flucytosine 100 O mg/kg per d for 14 days </li></ul></ul><ul><ul><li>followed by 8 to 10 weeks of oral fluconazole </li></ul></ul><ul><li>Lifelong maintenance therapy with fluconazole (200 mg per d) </li></ul>
  45. 45. Seizure in HIV DDx electrolyte imbalance
  46. 46. Opthalmologic <ul><li>75% </li></ul><ul><ul><li>The most common ophthalmic finding in patients with AIDS is retinal microvasculopathy </li></ul></ul><ul><ul><li>retinal cotton-wool spots identical to be incidental and do not cause visual disturbances </li></ul></ul><ul><ul><li>The diagnostic dilemma is to distinguish these findings from early CMV infection, and ophthalmologic consultation is recommended. </li></ul></ul>
  47. 47. CMV retinitis <ul><li>unilateral vision loss. If untreated, the condition progresses to bilateral blindness. </li></ul><ul><li>The funduscopic examination </li></ul><ul><ul><li>exudates </li></ul></ul><ul><ul><li>hemorrhages </li></ul></ul><ul><ul><li>E dema </li></ul></ul><ul><ul><li>dense </li></ul></ul><ul><ul><li>opaque lesions </li></ul></ul><ul><ul><li>&quot;cottage cheese and ketchup&quot; appearance </li></ul></ul>
  48. 48. ED management <ul><li>First-line treatment </li></ul><ul><ul><li>intraocular ganciclovir implant with oral ganciclovir 1.0 to 1.5 g PO tid </li></ul></ul><ul><ul><li>alternative first-line therapy is ganciclovir 5 mg/kg IV bid for 14 to 21 days. </li></ul></ul><ul><ul><li>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. </li></ul></ul>
  49. 49. Herpes Zoster Othalmicus
  50. 50. Herpes Zoster Othalmicus <ul><li>paresthesia and discomfort in the distribution of cranial nerve V 1 , followed by the appearance of the typical zoster skin rash. </li></ul><ul><li>Ocular complications include conjunctivitis, episcleritis, iritis, keratitis, secondary glaucoma, and rarely, retinitis </li></ul><ul><li>Preferred treatment is intravenous ayclovir (30–36 mg/kg per d) for at least 7 days. The role of maintenance therapy is unclear </li></ul>
  51. 51. Next week coming <ul><li>Thanks </li></ul><ul><li>Question </li></ul>