HIV - AIDS (main): Difference between revisions

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==Background==
==Background==
* In HIV+ patient presenting to ED, absolute lymphocyte count (ALC) can be used as surrogate for CD4 count <ref> Napoli AM, Fischer CM, Pines JM, Soe-lin H, Goyal M, Milzman D. Absolute
*In HIV+ patient presenting to ED, absolute lymphocyte count (ALC) can be used as surrogate for CD4 count <ref> Napoli AM, Fischer CM, Pines JM, Soe-lin H, Goyal M, Milzman D. Absolute
lymphocyte count in the emergency department predicts a low CD4 count in admitted
lymphocyte count in the emergency department predicts a low CD4 count in admitted HIV-positive patients. Acad Emerg Med. 2011 Apr;18(4):385-9. doi:10.1111/j.1553-2712.2011.01031.x. Erratum in: Acad Emerg Med. 2011 May;18(5):565.</ref>
HIV-positive patients. Acad Emerg Med. 2011 Apr;18(4):385-9. doi:
**A CD4 count of <200 is very likely if the ED ALC is <950 and less likely if the ALC is >1700
10.1111/j.1553-2712.2011.01031.x. Erratum in: Acad Emerg Med. 2011 May;18(5):565. </ref>.
**ALC is useful to confirm, but not exclude a low CD4
* A CD4 count of <200 is very likely if the ED ALC is <950 and less likely if the ALC is >1700.
*Approximately 1.2 million people in the US are living with HIV <ref name="HIV">CDC. Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data. HIV Surveillance Report. 2015; 20(2):1-70.</ref>
* ALC is useful to confirm, but not exclude a low CD4
**13% of people with HIV in US aren't aware <ref name="HIV"></ref>
**Most affected: homosexual & bisexual men, particularly African American <ref name="HIV"></ref>


{{HIV CD4 Chart}}
{{HIV CD4 Chart}}


==Clinical Features==
==Clinical Features==
[[File:PMC3218701 hiv-2-089f1.png|thumb|View of posterior pharynx showing [[pseudomembranous oropharyngeal candidiasis]] in a patient with HIV, with a distribution concerning for esophageal candidiasis (later found on scope).]]
[[File:Kaposis sarcoma 01.jpg|thumb|[[Kaposi sarcoma]]. Characteristic purple lesions on the nose in an HIV-positive female.]]
[[File:Kaposis Sarcoma Lesions.jpg|thumb|[[Kaposi's sarcoma]] skin lesion]]
[[File:Patch stage Kaposi's sarcoma.jpg|thumb|Patch stage [[Kaposi's sarcoma]]. Red to brownish irregularly shaped macules and plaques.]]
[[File:Kaposi’s sarcoma intraoral AIDS 072 lores.jpg|thumb|An HIV-positive person presenting with a [[Kaposi's sarcoma]] lesion with an overlying candidiasis infection in their mouth.]]
[[File:Fundus photograph-CMV retinitis EDA07.jpg|thumb|Fundus photograph of [[CMV retinitis]]]]
===Acute Infection===
===Acute Infection===
*Misdiagnosed frequently as "mono" or "flu"
*Misdiagnosed frequently as "mononucleosis" or "flu"
*Largest viral load, widespread dissemination of virus, and most infectious stage<ref>Serrano KD, Westergaard RP. Diagnosis and management of acute HIV in the emergency department. EM Reports, 2012:33;16.</ref>
*Symptoms develop 2-4wks after exposure; last for <14d
*Symptoms develop 2-4wks after exposure; last for <14d
**[[Fever]] (>90%)
**[[Fever]] (>90%)
**Fatigue (70-90%)
**Fatigue (70-90%)
**[[Pharyngitis]] (>70%)
**[[Pharyngitis]] (>70%)
**Rash (40-80%)
**Rash (40-80%) - [[Pruritic papular eruption of HIV]]
**Headache (30-70%)
**[[Headache]] (30-70%)
**[[Lymphadenopathy]] (40-70%)
**[[Lymphadenopathy]] (40-70%)


===Seroconversion===
===Seroconversion===
*HIV Ab detectable 3-8wk after infection
*HIV Ab detectable 3-8wk after infection (sometimes sooner)
*If negative Ab test but high suspicion, can HIV viral load.


===Asymptomatic===
===Asymptomatic===
*Lasts for ~8yr
*Lasts for ~8yr
*Pts may have conditions that are more common in pts w/ HIV but no indicator conditions
*Patients may have conditions that are more common in patients with HIV but no indicator conditions
**Thrush
**[[Thrush]]
**Persistent vulvovaginal candidiasis
**Persistent [[Candidiasis|candidia vaginitis]]
**Peripheral neuropathy
**Peripheral neuropathy
**Cervical dysplasia
**Cervical dysplasia
**Recurrent [[Herpes Zoster]]
**Recurrent [[Herpes Zoster]]
**ITP
**[[ITP]]
**Unexplained weight loss


===AIDS===
===AIDS===
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**Disseminated [[TB]]
**Disseminated [[TB]]
**Invasive cervical cancer
**Invasive cervical cancer
**Esophageal candidiasis
**[[Esophageal candidiasis]]
**[[Cryptococcosis]]
**[[Cryptococcosis]]
**[[Cryptosporidiosis]]
**[[Cryptosporidiosis]]
**[[CMV  Retinitis]]
**[[CMV  Retinitis]]
**HSV
**[[HSV]]
**[[Kaposi sarcoma]]
**[[Kaposi sarcoma]]
**Brain lymphoma
**[[Pruritic papular eruption of HIV]]
**MAC
**[[Primary CNS lymphoma|Lymphoma]]
**PCP PNA
**[[Mycobacterium avium|MAC]]
**PML
**[[PCP pneumonia]]
**[[Progressive multifocal leukoencephalopathy]]
**Brain [[Toxoplasmosis]]
**Brain [[Toxoplasmosis]]
**HIV [[Encephalitis]]
**HIV [[Encephalitis]]
**HIV wasting syndrome
**HIV wasting syndrome
**Disseminated histoplasmosis
**Disseminated [[histoplasmosis]]
**Isosporiasis
**Isosporiasis
**Recurrent [[Salmonella]] septicemia  
**Recurrent [[Salmonella]] septicemia  
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{{HIV associated conditions}}
{{HIV associated conditions}}


==Neurologic Complications==
==Evaluation==
*Work-Up
[[File:PMC4536784 ccrpm-suppl.1-2015-019f3.png|thumb|CT of [[Pneumocystis jirovecii pneumonia]], showing small nodular lesions surrounded by diffuse GGO.]]
**CT Head w/o contrast
*Typical lab testing for HIV:
**LP
**Screening test: ELISA
***Regular studies + (India ink, viral culture, fungal culture, toxo, crypto, coccidio)
**Confirmatory test: Western blot
*Specific Conditions:
*Maintain low threshold for additional testing in setting of suspicion of opportunistic infections
**[[Toxoplasmosis]]
*CDC (2006) recommends routine HIV screening in health care settings using an opt-out approach <ref>Branson B, Handsfield H, Lampe M. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. MMWR. 2006; 55: 1-17.</ref>
**[[Cryptococcosis]]
**Opt-out screening: performing the test after notifying the patient it will be performed & giving them the option to decline
**[[AIDS Dementia]]
 
==Pulmonary Complications==
*Most common cause of PNA in HIV-infected pt is Strep pneumo, NOT PCP
*Cannot use PORT score to dispo pts
*Work-Up
**ABG
**Sputum cx, GS, AFB
**Blood cx
**CXR
*Specific Infections
**[[Pneumocystis Pneumonia (PCP)]]
**[[Tuberculosis (TB)]]
 
==Ophthalmologic Complications==
*[[CMV Retinitis]]
*[[Herpes Zoster Ophthalmicus]]


==Management==
==Management==
===HAART===
'''Highly Active Anti-Retroviral Therapy'''
*Reduces progression to AIDS and transmission risk
*CDC Guidelines =  all HIV+ individuals should be started on HAART, regardless of CD4 count or viral load<ref>Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. https://aidsinfo.nih.gov/guidelines Accessed 03/04/16</ref>
*Typical first line regimens include a reverse transcriptase inhibitor (NRTI) and an integrase inhibitor
**tenofovir/emtricitabine (Truvada) '''PLUS''' raltegravir (Isentress)
**tenofovir/emtricitabine (Truvada) '''PLUS''' dolutegravir (Tivicay)


==Disposition==
==Disposition==
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*Cachexia or weakness
*Cachexia or weakness
*Unable to care for self/receive care
*Unable to care for self/receive care
*Unable to assure F/U
*Unable to assure follow up


===Suggested Discharge===
===Suggested Discharge===
*Normal or baseline vitals
*Normal or baseline vitals
*Stable medical condition
*Stable medical condition
*Able to tol POs/not orthostatic
*Able to tolerate PO
*F/U arranged
*Adequate follow-up
*Able to comply with D/C instructions
*Able to comply with discharge instructions


==See Also==
==See Also==
*[[HIV post-exposure prophylaxis]]
*[[HIV post-exposure prophylaxis]]
*[[AIDS FUO]]
*[[AIDS Dementia]]
*[[Pneumocystis Pneumonia (PCP)]]
*[[CMV Retinitis]]
*[[Seizures in patients with HIV-AIDS]]
*[[Immune reconstitution inflammatory syndrome]]
*[[Immune reconstitution inflammatory syndrome]]
==External Links==
*http://www.cdc.gov/hiv/


==References==
==References==
<references/>
<references/>
[[Category:ID]]
[[Category:ID]]

Latest revision as of 17:18, 25 January 2023

Background

  • In HIV+ patient presenting to ED, absolute lymphocyte count (ALC) can be used as surrogate for CD4 count [1]
    • A CD4 count of <200 is very likely if the ED ALC is <950 and less likely if the ALC is >1700
    • ALC is useful to confirm, but not exclude a low CD4
  • Approximately 1.2 million people in the US are living with HIV [2]
    • 13% of people with HIV in US aren't aware [2]
    • Most affected: homosexual & bisexual men, particularly African American [2]

HIV Associated Diseases by CD4 Level

CD4 Count Stage Diseases
>500 Early disease Similar to non-immunocompromised patients (Consider HAART medication side-effects)
200-500 Intermediate disease Kaposi's sarcoma, Candida, bacterial respiratory infections
<200 Late disease PCP, central line infection, MAC, TB, CMV, drug fever, sinusitis, endocarditis, lymphoma, histoplasmosis, cryptococcus, PML
<100 Very late disease Cryptococcus, Cryptosporidium, Toxoplasmosis
<50 Final Stage CMV retinitis, MAC

Clinical Features

View of posterior pharynx showing pseudomembranous oropharyngeal candidiasis in a patient with HIV, with a distribution concerning for esophageal candidiasis (later found on scope).
Kaposi sarcoma. Characteristic purple lesions on the nose in an HIV-positive female.
Kaposi's sarcoma skin lesion
Patch stage Kaposi's sarcoma. Red to brownish irregularly shaped macules and plaques.
An HIV-positive person presenting with a Kaposi's sarcoma lesion with an overlying candidiasis infection in their mouth.
Fundus photograph of CMV retinitis

Acute Infection

Seroconversion

  • HIV Ab detectable 3-8wk after infection (sometimes sooner)
  • If negative Ab test but high suspicion, can HIV viral load.

Asymptomatic

  • Lasts for ~8yr
  • Patients may have conditions that are more common in patients with HIV but no indicator conditions

AIDS

Differential Diagnosis

HIV associated conditions

Evaluation

CT of Pneumocystis jirovecii pneumonia, showing small nodular lesions surrounded by diffuse GGO.
  • Typical lab testing for HIV:
    • Screening test: ELISA
    • Confirmatory test: Western blot
  • Maintain low threshold for additional testing in setting of suspicion of opportunistic infections
  • CDC (2006) recommends routine HIV screening in health care settings using an opt-out approach [5]
    • Opt-out screening: performing the test after notifying the patient it will be performed & giving them the option to decline

Management

HAART

Highly Active Anti-Retroviral Therapy

  • Reduces progression to AIDS and transmission risk
  • CDC Guidelines = all HIV+ individuals should be started on HAART, regardless of CD4 count or viral load[6]
  • Typical first line regimens include a reverse transcriptase inhibitor (NRTI) and an integrase inhibitor
    • tenofovir/emtricitabine (Truvada) PLUS raltegravir (Isentress)
    • tenofovir/emtricitabine (Truvada) PLUS dolutegravir (Tivicay)

Disposition

Suggested Admission

  • New presentation of fever of unknown origin
  • Hypoxemia worse than baseline or PaO2 <60
  • Suspected PCP
  • Suspected TB
  • New CNS symptoms
  • Intractable diarrhea
  • Suicidal
  • Suspected CMV retinitis
  • Ophthalmicus zoster
  • Cachexia or weakness
  • Unable to care for self/receive care
  • Unable to assure follow up

Suggested Discharge

  • Normal or baseline vitals
  • Stable medical condition
  • Able to tolerate PO
  • Adequate follow-up
  • Able to comply with discharge instructions

See Also

External Links

References

  1. ↑ Napoli AM, Fischer CM, Pines JM, Soe-lin H, Goyal M, Milzman D. Absolute lymphocyte count in the emergency department predicts a low CD4 count in admitted HIV-positive patients. Acad Emerg Med. 2011 Apr;18(4):385-9. doi:10.1111/j.1553-2712.2011.01031.x. Erratum in: Acad Emerg Med. 2011 May;18(5):565.
  2. ↑ 2.0 2.1 2.2 CDC. Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data. HIV Surveillance Report. 2015; 20(2):1-70.
  3. ↑ Serrano KD, Westergaard RP. Diagnosis and management of acute HIV in the emergency department. EM Reports, 2012:33;16.
  4. ↑ Gutteridge, David L MD, MPH, Egan, Daniel J. MD. The HIV-Infected Adult Patient in The Emergency Department: The Changing Landscape of the Disease. Emergency Medicine Practice: An Evidence-Based Approach to Emergency Medicine. Vol 18, Num 2. Feb 2016.
  5. ↑ Branson B, Handsfield H, Lampe M. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. MMWR. 2006; 55: 1-17.
  6. ↑ Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. https://aidsinfo.nih.gov/guidelines Accessed 03/04/16
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