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HIV infections (3) Viral (A) CMV (Diagnosis (History PC/HPC: eye symptoms…
HIV infections
3) Viral
B) Other herpes
viruses
Clinical presentation
HSV: genital/oral ulcers
Zoster: dermatomal itchy/painful rash
EBV: oral hairy leukoplakia, lymphoma
HHV8: purple mucosal lesions (KS)
Management
Aciclovir
Pathophysiology
HSV, Herpes zoster, EBV, HHV8
C) HPV
Pathophysiology
Low risk types 6, 11: skin/genital warts
High risk types 16, 18: SCC cervix, anus, oral
Clinical presentation
Genital, palmar, plantar warts
Anal mass, IMB/PCB (cervical)
A) CMV
Epidemiology
Common in HIV
CMV retinitis is an AIDS-defining illness
Pathophysiology
DNA virus of herpes family
Can infect retina, colon, oesophagus, CNS, lungs
Clinical presentation
Retinitis: floaters, reduced acuity, ocular pain
Colitis: bloody diarrhoea, abdo pain
Oesophagitis: sore throat
Encephalitis: confusion, headache, focal signs
Pneumonitis: dry cough, SOB, wheeze
Diagnosis
History
PC/HPC: eye symptoms, diarrhoea, sore throat, CNS signs, LRTI
PMH: known HIV+, other conditions
DH: HAART, allergies
SxH: partners, gender, contraception, HIV status, BBV risk
SH: occupation, social support, smoking, alcohol, drugs
Investigations
Bedside: obs (fever)
Bloods: FBC, CRP (infection), U+E, LFT,
HIV +ve), CMV (+ve)
Imaging: colonoscopy + biopsy (CMV cells)
Examination
Fundoscopy: mozarella pizza retina
Neurological: CN palsies, focal signs, UMN signs, reduced GCS
Abdominal: tenderness
Respiratory: wheeze, coarse crackles
Management
Conservative
Information, advice, support
Medical
Antivirals
Indication: all patients
E.g. ganciclovir eye implant, PO ganciclovir
MOA: inhibits viral replication
D) JCV
Pathophysiology
Papovavirus, causing progressive
multifocal leukoencephalopathy (PML)
Clinical presentation
Intellectual impairment
Focal signs (hemiparesis, CN palsies, ataxia, aphasia)
Diagnosis
History: neurological S+S
Examination: UMN lesions
Investigations: CT head white matter changes
E) Hepatitis
viruses
Pathophysiology
Infection with HBV (DNA virus) or HCV (RNA virus)
HIV accelerates HCV progression and vice versa
HIV increases likelihood of chronic HBV infection
Epidemiology
Commonly co-infected with HIV
(same transmission routes)
1) Fungal
C) Candida
Clinical presentation
Creamy plaques
Odonophagia
Dysphagia
Itch and pain
Management
Medical
Antifungal
E.g. nystatin (oral), fluconazole/ketoconazole/itraconazole (oesophageal), amphoteracin B (disseminated)
Conservative
Information, advice, support
Pathophysiology
Candida albicans infection
Often moist areas e.g. mouth, groin, oesophagus
A) P. Jirovicii (PCP)
Clinical presentation
Chronic SOB
Dry cough
Fever
Malaise
Management
Conservative
Information, advice support
Medical
Abx
Indication: all patients
E.g. co-trimoxazole or pentamidine
MOA: kill fungi (fungicidal)
SEs: N+V, fever, rash, myelosuppression
Steroids
Indication: severe hypoxia
E.g. high dose prednisolone
MOA: reduces inflammation
Pathophysiology
Fungus causing pneumonia
Insidious onset
Diagnosis
History
PC/HPC: chronic SOB, dry cough, fever malaise
SxH: partners, contraception, HIV status, BBV risk
SH: occupation, social support, smoking, alcohol, drugs
Examination
Respiratory: wheeze, crackles, may have signs of pneumothorax
Investigations
Bedside: obs (fever)
Bloods: FBC, CRP (infection), U+Es, HIV (+ve)
Sputum: culture for PCP (+ve), bronchoalveolar lavage (silver stain/PCR)
Imaging: CXR (normal, bilateral perihilar infiltrates, diffuse shadowing),
HRCT (abnormalities seen)
Epidemiology
Pneumonia in underdeveloped countries
Prevention
Abx prophylaxis
Secondary prevention with co-trimoxazole
B) Crypotococcus
Clinical presentation
Insidious fever, headache, nausea
Impaired conciousness, coma
NO neck stiffness
Diagnosis
History
PC/HPC: fever, headache, impaired conciousness
PMH: known HIV, other HIV complications
DH: HAART, other meds, allergies
SxH: partners, gender, contraception, HIV status, BBV risk
SH: occupation, support, alcohol, smoking, drugs
Examination
Neurological: focal signs, UMN signs, reduced GCS
Investigations
Bedside: obs (fever)
Bloods: FBC (infection), CRP (infection), U+E, LFTs, HIV (+ve)
LP: +ve cryptococcal Ag, India ink, MCS (do CT first to exclude raised ICP)
CT head: exclude SOL
Management
Conservative
Information, advice, support
Medical
Antifungal
Indication: all aptents
E.g. amphoteracin B plus 5-flucytosine
MOA: fungicidal
Surgical
VP shunt
Indication: chronic hydrocephalus
MOA: shunt connecting ventricles to abdominal peritoneal cavity, allowing CSF draining, reducing ICP
Pathophysiology
Fungus causing a chronic meningitis
Can also cause lung and skin infection
Spread by pigeon droppings (spores)
Prevention
Secondary prophylaxis (fluconazole)
2) Protozoal
B) Cryptosporidia,
microsporidia, cyclospora
Diagnosis
History
PC/HPC: abdo pain, diarrhoea, red flags
PMH: known HIV, other conditions
DH: HAART, other meds, allergies
SxH: partners, gender, contraception, HIV status, BBV risk
SH: occupation, social support, alcohol, smoking, drugs
Investigations
Bedside: obs (fever)
Bloods: FBC, CRP (infection), LFTs (cholangitis),
U+Es, HIV (+ve)
Stool sample: cysts/spores
Imaging: endoscopy and small bowel biopsy (cysts/spores)
Examination
Abdo: tenderness, dehydration
Clinical presentation
Diffuse, watery diarrhoea
Abdominal pain
Management
Conservative
Information, advice, support
Hydration and nutrition
Antiparasitic
E.g. albendazole
Pathophysiology
Parasite infecting the GIT, causing diarrhoea
C) Leishmania
Clinical presentation
Oriental sore (itchy, then ulcerates, then scar)
Mucosal and skin lesions
Systemic disease (kala-azar): feverr, sweats, arthralgia, cough, abdo pain, warty, pigmented skin lesions
Diagnosis
History
PC/HPC: itchy sore, systemic symptoms, red flags
PMH: known HIV, medical conditions
DH: HAART, allergies
SxH: partners, gender, contraception, HIV status, BBV risk
SH: occupation, social support, alcohol, smoking, drugs
Examination
Derm: itchy sore, ulcerated, scarring, mucosal lesions
Investigations
Bedside: obs (fever)
Bloods: FBC, CRP (infection), U+E, LFTs, HIV (+ve)
Swabs: MCS from ulcer, Ab test for ELISA, PCR
Pathophysiology
Sandfly spread, inject parasites at bite site
Induce immune response, spread via lymphatics throughout body
Epidemiology
S America, Africa, Mediterranian
Management
Conservative
Information, advice, support
Medical
Antiparasitic
E.g. topical paramomycin, PO fluconazole, amphoteracin B
1) Toxoplasma
Diagnosis
Examination
Neurological: focal signs, seizures, reduced GCS
Investigations
Bedside: obs (fever)
Bloods: FBC, CRP (infection), U+E, LFTs
HIV (+ve), T gondi (+ve)
Imaging: CT head (ring-shaped contrast-enhancing lesions
History
HPC: focal signs, fever, headache
PMH: known HIV, other conditions
DH: HAART, allergies
SxH: partners, gender, contraception, HIV status, BBV risk
SH: occupation, social support, alcohol, smoking, drugs
Management
Conservative
Information, advice, support
Medical
AEDs
Indication: seizures
E.g. levatiracetam, valproate
Antifungal
E.g. pyrimethamine plus sulfasalazine/clindamycin 6m
MOA: kills T. gondii parasite
Clinical presentation
Headache
Fever
Focal signs
Seizures
Confusion, coma
Pathophysiology
T gondii parasite causes encephalitis an cerebral abscesses
Prevention
Lifelong secondary prophylaxis
4) Bacterial
B) MAI
Clinical presentation
Fever, anorexia, weight loss,
diarrhoea
Diagnosis
History
PC/HPC: non-specific, red flags
PMH: HIV +ve, other medical conditions
DH: HAART, allergies
SxH: partners, gender, contraception. HIV status, BBV risk
SH: occupation, social support, alcohol, smoking, drugs
Investigations
Bedside: obs (fever)
Bloods: FBC, CRP (infection), U+E, LFTs,
HIV (+ve)
Sputum: MCS (mycobacteria)
CXR: normal or non-specific signs
Examination
General, abdominal, respiratory
Pathophysiology
Opportunistic mycobacterium
Late stage, once profoundly immunosuppressed
Management
Conservative
Information, advice, support
Medical
Triple abx (ethambutol, clarithromycin, rifambutin)
then erythromycin prophylaxis
A) TB
Pathophysiology
Pulmonary or extrapulmonary disease
Clinical presentation
Pulmonary: cough, SOB, sputum, haemoptysis,
fevers, night sweats, weight loss
Epidemiology
Commonly co-infected with HIV
Diagnosis
History
HPC/PC: prolonged productive cough, red flags
PMH: known HIV, other medical conditions
DH: HAART, allergies
SxH: partners, gender, contraception, HIV status, BBV risk
SH: occupation, social support, alcohol,smoking, drugs
Investigations
Bedside: obs (fever, tachycardia)
Bloods: FBC, CRP (infection), U+Es, LFTs
Sputum: 3x cultures MCS
Imaging: CXR (norm, ground glass, consolidation, nodules, cysts)
Examination
Respiratory: wheeze, coarse crackles
Management
Conservative
Information, advice, support
Isolation (negative pressure room)
Testing and treatment of contacts
Medical
Anti-TB
Indication: all patients
E.g. rifampicin, isoniazid (6m), pyrazinamide, ethambutol (4m)
MOA: kill mycobacteria
SEs: immune constitution of inflammatory response (IRIS) if HAART taken simaultaneously, also toxic interactions with HAART; often better to delay HAART until anti-TB completed