1
Q
Name 6 respiratory opportunistic infections in HIV positive
A
- Tb
- pneumocystis pneumonia (pjp)
- CMV pneumonia
- mycobacterium avium complex (MAC)
- fungal pneumonia: aspergillosis, histoplasma capsulatum
- parasitic pneumonia: toxoplasma gondii
2
Q
Treatment cryptococcal meningitis with HIV? (4)
A
- induction phase: Amphotericin B and flucytosine for 1 week
- continuation phase: then fluconazole for 1 week
- maintenance phase: Continue maintenance treatment for at least 12 months until CD4 > 200 and vl suppressed
- defer ARTs 4-6 weeks
3
Q
Treatment for HIV with CD4 < 200
A
Prophylactic bactrim for PCP
4
Q
Name 2 types IRIS
A
- Paradoxical
- unmasking
5
Q
Name 5 causes high viral load in HIV
A
ABCDE
- adherence
- bugs / Iris
- inCorrect dose
- drug interactions
- rEsistance
6
Q
WHO HIV clinical stage 1? (2)
A
- Asymptomatic
- persistent generalised lymphadenopathy
7
Q
WHO HIV clinical stage 2? (8)
A
- Unexplained moderate weight loss (<10% body weight)
- recurrent URTI
- hzv
- angular cheilitis
- recurrent oral ulcers
- papular pruritic eruptions
- seborrheic dermatitis
- fungal nail infections
8
Q
WHO HIV clinical stage 3? (9)
A
- Unexplained severe weight loss (>10%)
- unexplained chronic diarrhoea > 1 month
- unexplained persistent fever > 37,5 for > 1 month
- persistent oral candida
- oral hairy leukoplakia
- pulmonary tb!
- severe bacterial infections
- acute necrotising ulcerative stomatitis/ gingivitis/periodontitis
- unexplained anaemia (<8), neutropenia (<0,5), chronic thrombocytopenia (<50)
9
Q
WHO HIV clinical stage 4? (10)
= AIDS
A
- Invasive Cervical carcinoma
- extrapulmonary cryptococcosis
- HIV encephalopathy
- HIV wasting syndrome
- Kaposi sarcoma
- lymphoma
- non-tb / extrapulmonary disseminated mycobacterium infection
- pneumocystis pneumonia; recurrent bacterial pneumonia
- recurrent sepsis
- symptomatic HIV associated nephropathy
- symptomatic HIV associated cardiomyopathy
- candidiasis of oesophagus/ trachea/ bronchi / lungs; cryptosporidiosis > 1 month; cystoisosporiasiS > 1 month; disseminated endemic mycosis eg histoplasmosis; cerebral toxoplasmosis; atypical disseminated leishmaniasis
- CMV outside liver, spleen, nodes; HSv > 1 month
- progressive multi focal leucoencephalopathy
10
Q
Treatment PJp?
A
Trimethoprim / sulfamethoxazole (cotrimoxazole/ bactrim) 20/100 mg/kg/day in 4 divided doses for 21 days
(Alternative = clindamycin 900mg 3x daily iv, switch to 600mg Tds oral once improving, + primaquine 30mg daily for 21 days)
11
Q
Prophylaxis pjp?
A
When CD4 < 200
Cotrimoxazole (bactrim) (trimethoprim sulfamethoxazole) 160/800 mg daily
12
Q
Treatment cerebral toxoplasmosis in HIV?
A
- Sulfadiazine +
- pyrimethamine +
- folinic acid
( alt=bactrim)
13
Q
What does Bactrim prevent when given for HIV CD4 < 200? (3)
A
- Pneumocystis jirovecii pneumonia
- cerebral toxoplasmosis
- cystoisospora belli diarrhoea
Also: bacterial pneumonia, bacteraemia, malaria
14
Q
Prevention therapy for cryptococcosis in HIV when CD4 < 200?
A
Fluconazole 200 mg daily for minimum 1 year
15
Q
Treatment oesophageal candidiasis in HIV?
A
Fluconazole 200mg daily for 14 days
16
Q
Treatment disseminated mycobacterium avium complex in HIV?
A
- Clarithromycin 500mg bd +
- ethambutol 15mg / kg daily
For minimum 1 year
17
Q
What prophylaxis should HIV with CD4 < 200 be on
A
- Bactrim 160 / 800 mg daily
- fluconazole 200 mg daily
18
Q
What causes oral hairy leukoplakia
A
EBV
19
Q
Bacterial pneumonia vs PCP vs tb? (5) (duration, dyspnoea, wcc, CXR, CRP)
A
- Duration acute vs subacute vs variable
- dyspnoea common vs prominent! Vs occasional
- wCC increased us normal us variable
- CXR: consolidation vs interstitial bilateral infiltrate vs variable bilateral infiltrate + effusion + nodes
- CRP markedly increased vs variable vs increased
20
Q
Diagnosis PCP?
A
Induced Sputum or bronco - alveolar lavage:
- Silver stains
- pcr
- immunofluorescence
21
Q
How does Tb present in HIV with CD4 < 200? (4)
A
- Subacute/acute presentation with rapid progression
- CXR different: rarely cavities, pulmonary infiltrates not predominantly inapical areas. Pleural effusions + hilar lymphadenopathy common. Can be normal.
- sputum smears negative in > 50% patients due to absence of pulmonary cavities
- many have disseminated tb, sometimes military pattern on CXR - usually pleura or LNS.
22
Q
What is progressive multifocal leucoencephalopathy (pml)
A
HIV related neurological disorder
Presents with stroke-like episodes with cognitive impairment.
Usually visual impairment caused by involvement of occipital cortex
Caused by JC virus
No rx.
23
Q
Most common space-occupying lesions in hiV?
A
Cerebral toxoplasmosis
24
Q
Name 3 AIDS defining cancers
A
- Kaposi sarcoma
- cervical cancer
- non Hodgkin lymphoma (ebv related)
25
Alternative prophylaxis PCP when cotrimoxazole poorly tolerated?
Dapsone ( sulfone - usually used for leprosy) 100 mg
= efficacy for PCP, but doesn't prevent the other opportunistic infections like bacterium does
26
MAC prevention in HIV?
Azithromycin or clarithromycin if CD4 <50 until >100
Same to treat
27
Which vaccines should be given to HIV patients (3)
Nb to wait until CD4 > 200!
- conjugate pneumococcal vaccine
- annual influenza
- hep B if not immune
BCG and other live vaccines contraindicated!
28
Name 5 nrti
- Lamivudine!
- tenofovir!
- abacaVir
- emtricitabine
- zidovudine
29
Name nnrti
Efavirenz
Rilpivirine
30
Name protease inhibitors
- Lopinavir
- ritonavir
- atazanavir
31
Name integrate inhibitors
- Dolutegravir
- raltegravir
- elvitegravir
32
How and when should ART be deferred (3)
- Major opportunistic infections: start within 2 weeks
- cryptococcal meningitis: defer for 5 weeks
- tb meningitis: defer for 8 weeks unless CD4 < 50.
33
Which 3 drugs Treat both HIV and Hepatitis B?
• Tenofovir (nrti) (most effective)
• lamivudine (3Tc) (nnrti) or FTC emtricibine (nrti)
LET
34
Name 4 contraindications to tenofovir TDF
•age <10 or weight <35 kg
• renal failure eGFR <50
• Osteoporosis
• use of additional nephrotoxic drug es aminoglycoside
35
Name 3 contraindications to 3Tc lamivudine
• Pancreatitis
• bone marrow suppression (complications)
• renal failure
36
Name 2 contraindications to DTG dolutegravir
• intolerance
• high dose metformin
37
Name 5 drug interactions with dolutegravir
• Rifampicin decrease dolutegravir
• anticonvulsants (carbamazepine, phenobarbital, phenytoin, valproate) decrease dolutegravir
• dolutegravir increase metformin dose (too high = lactic acidosis)
• calcium and or iron supplements decrease dolutegravir levels if taken without food
• antacids (magnesium or aliminium) decrease dolutegravir levels
38
How should dolutegravir be taken with rifampicin?
Double dolutegravir dose to 50 mg 12 hourly
If on TLD (Tenofovir, lamivudine, dolutegravir) FDC, add dolutegravir 50 mg 12 hours
after TLD dose
39
What is pathopneumonic of PCP?
Hypoxia especially after exercise
Also tachypnoea
40
Define Iris
Immune reconstitution inflammatory syndrome
Excessive inflammatory response to preexisting antigen or pathogen and a paradoxical deterioration in clinical status after art initiation
Diagnosis ot exclusion
2 types: unmasking and paradoxical Iris
41
What is paradoxical Iris?
Worsening symptoms of known disease, either at new or original body site
42
What is unmasking Iris?
Occult opportunistic infection not clinically apparent prior to art
Type of art associated illness
43
Name 5 side effects dolutegravir
Usually mild and self limiting.
• insomnia
• headache
• CNS effects: depression
• gastrointestinal: increase serum creatinine
• weight gain
• neural tube defects: avoid preconception and first 6 weeks pregnancy
44
Benefits using DTG instead of EFV? (3)
• High genetic barrier to resistance
• no interaction with hormonal contraceptives
• side effects mild and uncommon (efavirenz neuropsychiatric,)
45
Benefits using efavirenz instead of dolutegravir? (3)
• safe in pregnancy
• no significant interaction with Tb treatment (at interact with rifampin)
• better for obese patients (dolutegravir: weight gain)
46
How should polyvalent cations be taken with dolutegravir
(4)
• Take calcium and DTG together with food (only decrease DTG on empty stomach)
• take iron with DTG with food
• calcium and Iron must be taken at least 4 hours apart
• magnesium/aliminium containing antacids should be taken minimum 2 hours after or 6 hours before DTG
47
Name side effect lamivudine
Generally well tolerated. Rarely pure red cell aplasia causing anaemia
48
Define art treatment failure
Unsuppressed viral load >1000 for >3 months
49
Tb preventative therapy in HIV?
Isoniazid for 6 months.
If positive tuberculin skin test: 36 months
Rifampicin + isoniazid for 12 weeks equally effective as Isoniazid for 6 months
50
Name regimen used for HIV pre-exposure prophylaxis
Tenofovir + embricitabine
(both nrti)
51
How is hepatitis D spread
Need HBV
Close contact, blood, vertical transmission
52
How is hepatitis D spread
Blood
Saliva
