Term
|
Definition
dictates the need for OI prophylaxis;
affects differential diagnosis of OIs |
|
|
Term
| Advantages of ART in setting of an acute OI (Tx-Naive pts) |
|
Definition
preventative benefits;
effective for OIs for which effective therapy does not exist; |
|
|
Term
| Disadvantages of ART in setting of an acute OI (Tx-Naive Pts) |
|
Definition
severely ill may not absorb ART well -> subtherapeutic levels --> RESISTANCE;
ART toxicities may be confused w/ dx manifestations;
DDIs;
Renal & hepatic dysfunction;
Immune Resconsitution Inflammatory Syndrome (IRIS); |
|
|
Term
| Immune Reconsitution Inflammatory Syndrome (IRIS) |
|
Definition
Initiation of ART improves immune function -> fever & worsening of clinical manifestations of underlying OIs - at site of previously recognized OI or might "unmask" disease at new site;
Commonly with: TB, MAC, PCP, toxplasmosis, Hep B & C, CMV, VZV, Cryptococcus;
Presentation: ~4-8 wks after starting ART in pts w/ HIGH VL & LOW CD4+ count;
Therapy (empiric):
- no consensus on use of corticosteroids & decision to halt or continue ART;
Generally ART is continued w/ presence of this phenomenon; |
|
|
Term
| Primary Prophylaxis of OIs |
|
Definition
initiated before the appearance of an OI;
Recommended for:
- Pneumocystis jiroveci (PCP)
- Toxoplasma gondii
- Mycobacterium avium complex (MAC)
D/C if:
- pts on ART
- CD4+ count rises above specified threshold;
NOT Recommended for:
- Cryptococcus neoformans
- Cytomegalovirus (CMV) |
|
|
Term
| Secondary Prophylaxis of OIs |
|
Definition
prevents recurrence of an OI;
Recommended for:
- Pneumocystis jiroveci (PCP)
- Toxoplasma gondii
- Mycobacterium avium complex (MAC)
NOT recommended for:
- Cryptococcus neoformans
- CMV
D/C if:
- pt on ART
- CD4+ count rises above specified threshold
- asymptomatic |
|
|
Term
| Pneumocystis jiroveci Pneumonia (PCP) |
|
Definition
fungus spread by airborn route;
Before prophylaxis & ART:
- **~90% occurred with CD4+ counts <200 cells/mm^#**
Clinical Presentation:
- progressive dyspnea
- fever
- nonproductive cough
- chest pain;
CXR: diffuse bilateral interstitial pulmonary infiltrates (Butterfly Effect)
Mild-to-Moderate: A-a O2 grad <35 mmHg OR room PaO2 >= 70 mmHg;
Moderate: A-a O2 grad >35 & <45 mmHg OR PaO2 <70 mmHg;
Severe: A-a grad >45 mmHg OR PaO2 <70 mmHg;
- should receive CORTICOSTEROIDS ASAP (w/in 72 hrs of starting therapy)
REQUIRED FOR DIFFERENTIAL DIAGNOSIS:
- histopathologic evidence in tissue
- brochoalveolar lavage (BAL) fluid
OR
- induced sputum samples |
|
|
Term
| A-a (alveolar-arterial) Gradient |
|
Definition
|
|
Term
| Preferred Tx for Moderate to Severe PCP |
|
Definition
TMP/SMX 15-20 mg/kg IV divided q6-8 hr x 21 days
**dosing of TMP/SMX is ALWAYS based on TMP dose (more severe SEs) |
|
|
Term
| Preferred Tx for Mild to Moderate PCP |
|
Definition
TMP/SMX 15-20 mg/kg PO divided TID x 21 days
OR
TMP/SMX 2 DS tabs PO TID x 21 days |
|
|
Term
| Alternative Therapy for Moderate to Severe PCP |
|
Definition
pentamidine IV daily x 21 days
OR
primaquine PO + clindamycin IV/PO x 21 days |
|
|
Term
| Alternative Tx for Mild to Moderate PCP |
|
Definition
dapsone PO + TMP PO in 3 divided doses x 21 days
OR
primaquine PO + clindamcyin IV/PO x 21 days
OR
atovaquone PO suspension x 21 days |
|
|
Term
| Prednisone PO or IV Methylprednisolone |
|
Definition
If pt w/ PCP is hypoxic:
- PaO2 <70 mmHg or A-a O2 gradient >35 mmHg;
Recommended to be started within 72 hrs of PCP therapy |
|
|
Term
|
Definition
RASH (SJS) - 80% of HIV+ pts develop rash;
fever;
Leukopenia, Thrombocytopenia; |
|
|
Term
|
Definition
methemoglobinemia;
HEMOLYSIS (test for G6PD deficiency before use);
rash;
fever |
|
|
Term
|
Definition
azotemia;
PANCREATITIS;
Hypo- or HYPERGLYCEMIA;
leukopenia;
fever;
ELECTROLYTE ABNORMALITIES;
cardiac dysrhythmia |
|
|
Term
|
Definition
HEMOLYTIC ANEMIA (test for G6PD deficiency before use);
methemoglobinemia |
|
|
Term
|
Definition
HA;
N, D, rash, fever, transaminase elevation |
|
|
Term
| Primary & Secondary Prophylaxis for PCP: TMP/SMX SS or DS |
|
Definition
Indications:
- CD4 <200 OR oropharyngeal candidias OR CD4+ <14% or history of AIDS-defining illness;
Preferred Tx: TMP/SMX 1 DS PO daily OR TMP/SMX 1 SS PO daily
Immune Reconsitution: D/C if CD4 >200 for >3 months;
Restart:
- CD4 decreases to <200 (or if PCP recoccurs at CD4 >200) |
|
|
Term
| Toxoplasma gondii Encephalitis (TE) |
|
Definition
protozoa;
Primary infection after:
- eating uncooked meat containing tissue cysts
- ingestion of oocysts that sheds in cat feces;
- not transmitted by person-to-person contact;
**COMMONLY occurs when CD4+ <100**
Clinical Presentation:
- Focal encephalitis: HA, confusion, motor weakness, fever
- Absence of Tx: seizure, stupor, coma;
CT Scan or MRI: multiple contrast-enhancing LESIONS w/ edema;
Brain Biopsy: indicated after tx failure |
|
|
Term
| Preferred Tx for Acute Toxoplasma gondii Encephalitis (TE) |
|
Definition
| pyrimethamine LD, then MD + sulfadiazine + leucovorin (prevents neutropenia) x 6 wks minimum |
|
|
Term
|
Definition
rash;
nausea;
BONE MARROW SUPPRESSION (neutropenia, anemia, thrombocytopenia): reversed by increasing leucovorin by 50-100 mg/day |
|
|
Term
|
Definition
| rash, fever, leukpenia, hepatitis, N/V, diarrhea, crystalluria |
|
|
Term
|
Definition
| fever, rash, Nausea, diarrhea, hepatotoxicity |
|
|
Term
| Primary Prophylaxis for TE |
|
Definition
Indications:
(+) anti-Toxoplasma IgG AND CD4 <100;
Preferred:
- TMP/SMX 1 DS PO daily
Immune Reconsitution: D/C if CD4 >200 for >3 months
Restart: CD4 decreases to <100-200 |
|
|
Term
| Secondary Prophylaxis for TE |
|
Definition
Indications:
CD4+ decreases to <200
Preferred:
- pyrimethamine + sulfadiazine + leucovorin (can no longer use TMP/SMX)
Immune Reconstitution:
D/C if CD4 >200 for > 6 (SIX) months
Restart:
CD4 decreases to <200 |
|
|
Term
| Mycobacterium Avium Complex (MAC) |
|
Definition
Ubuiquitous organisms transmitted mainly by inhalation & ingestion;
**COMMONLY occurs when CD4 <50**
Clinical Presentaiton:
- Early Symptoms: fever, night sweats, wt loss, fatigue, diarrhea, abd pain
- Immune Reconstitution Inflammatory Syndrome (IRIS): focal lymphadenitis w/ fever;
Localized Manifestations:
- cervical/mesenteric lymphadenitis
- pneumonitis
- pericarditis
- osteomyelitis
- skin & soft tissue abscesses
- genital ulcers
- CNS infections |
|
|
Term
|
Definition
| clarithromycin + ethambutol (+ rifabutin [severe dx]) x LIFELONG unless: 12 months tx AND asymptomatic AND CD4 >100 for >6 months |
|
|
Term
|
Definition
| azithromycin + ethambutol x LIFELONG unless: 12 months of tx AND asymptomatic AND CD4 >100 for >6 months |
|
|
Term
| ADRs for Clarithromycin & Azithromycin |
|
Definition
N/V, abd pain, abnormal taste, elevated liver transaminases, hypersensitivity rxns;
Doses >1 g of C in MAC associated w/ increased mortality & is NOT RECOMMENDED |
|
|
Term
|
Definition
retrobulbar neuritis (dose-related);
rash |
|
|
Term
|
Definition
Doses >= 450 mg:
- higher risk of ADRs when used with CLARITHROMYCIN or other CYP3A4 inhibitors |
|
|
Term
| Primary & Secondary Prophylaxis of MAC |
|
Definition
Primary Indication:
CD4 <50
Secondary Indication:
CD4 <100;
Preferred:
- azithromycin 1200 mg PO weekly
Immune Reconsitution:
- D/C if CD4 >100 for >= 3 months
Restart:
- CD4 decreases to <50 |
|
|
Term
| Mucocutaneous Candidiasis |
|
Definition
indicator of immunosuppression;
Majority caused by Candida albicans;
**COMMONLY occurs when CD4+ <200**
Primary prophylaxis NOT RECOMMENDED;
Secondary Prophylaxis may be considered in SEVERE RECURRENT INFECTIONS |
|
|
Term
| Treatment of Oropharyngeal Candidiasis (initial episode) |
|
Definition
| fluconazole 100 mg PO(IV) daily x 7-14 days |
|
|
Term
| Treatment of Esophageal Candidiasis |
|
Definition
| fluconazole 100-400 mg PO (IV) daily x 14-21 days |
|
|
Term
|
Definition
caused by Cryptococcus neoformans;
**Commonly occurs when CD4+ <50**
Clinical Presentation
- Meningitis (stiff neck, photophobia)
- fever, malaise, HA, encephalopathic Sx (lethargy, altered mental status, personality changes, memory loss);
CSF analysis via Lumber puncture (LP)
**UNtreated --> FATAL** |
|
|
Term
| Treatment of Cryptococcal Meningitis |
|
Definition
Induction:
amphotericin B IV + flucytosine PO x 2 weeks (until clinical improvement & negative CSF culture)
THEN
Consolidation Therapy:
- fluconazole PO x 8 wks |
|
|
Term
| ADRs of Conventional Amphotericin B |
|
Definition
nephrotoxicity;
electrolyte disturbances;
infusion-related ADRs;
lipid formuations - less toxic; |
|
|
Term
|
Definition
bone marrow suppression
GI toxicities |
|
|
Term
|
Definition
|
|
Term
| Primary Prophylaxis for Cryptococcal Meningitis |
|
Definition
NOT ROUTINELY RECOMMENDED;
- consider fluconazole when CD4 <50 |
|
|
Term
| Secondary Prophylaxis of Cryptococcal Meningitis |
|
Definition
Indication:
Chronic mainteneance therapy until immune reconsitution;
Preferred: fluconazole PO daily
Immune Reconstitution:
D/C if asymptomatic AND CD4 remains >=200 for >6 months
Restart:
- CD4 decreases to 200 |
|
|
Term
|
Definition
caused by a herpesvirus;
Clinical Presentation:
- asymptomatic
- floaters
- scotomata
- peripheral visual field defects; |
|
|
Term
|
Definition
Ganciclovir IV x 14-21 days, then IV daily
OR
valganciclovir PO x 14-21 days, then HD PO daily
OR
foscarnet IV (LD, MD)
OR
cidofovir IV q7 days then q14 days |
|
|
Term
| Primary Prophylaxis for CMV Retinitis |
|
Definition
|
|
Term
| Secondary Prophylaxis of CMV Retinitis |
|
Definition
Chronic maintenancy therapy until immune reconstitution;
System:
- valgancyclovir 900 mg PO daily
Continue until inactive dx + CD4 >100 x 3-6 months;
Restart:
CD4 decreases to <100 |
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|
