HIV - AIDS (main): Difference between revisions

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*Consider medication side effects: lactic acidosis, neuropyschiatric effects, hepatic toxicity, renal toxicity, Steven-Johnson's, cytopenias, GI symptoms, endocrine abnormalities. <ref> 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.</ref>
*Consider medication side effects: lactic acidosis, neuropyschiatric effects, hepatic toxicity, renal toxicity, Steven-Johnson's, cytopenias, GI symptoms, endocrine abnormalities. <ref> 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.</ref>


==Diagnostcally==
==Diagnosis==
*Lactic acidosis is a side effect of many of the anti-retroviral medications.
*Typical lab testing for HIV:
*Should have lower threshold for labs and imaging and cultures for OIs.
**Screening test: ELISA
**Confirmatory test: Western blot
*Lactic acidosis may be seen as a side effect of many anti-retroviral medications.
*Maintain low threshold for additional testing in setting of suspicion of opportunistic infections (OI)


==Management==
==Management==
CDC now recommends all HIV+ individuals be started on HAART since it decreases risk of progression to AIDS and decreases transmission risk.  
'''CDC now recommends all HIV+ individuals be started on HAART since it decreases risk of progression to AIDS and transmission risk.'''
(Treatment should be guided and initiated by ID)


Treatment should be guided and initiated by ID
*Typical first line regimens include a reverse transcriptase inhibitor (NRTI) and an integrase inhibitor
*Typical first line regimens include reverse transcriptase inhibitors (NRTI) and an integrase inhibitor
**tenofovir/emtricitabine (Truvada) '''PLUS''' raltegravir (Isentress)
**tenofovir/emtricitabine (Truvada) and raltegravir (Isentress)
**tenofovir/emtricitabine (Truvada) '''PLUS''' dolutegravir (Tivicay)
**tenofovir/emtricitabine (Truvada) and dolutegravir (Tivicay)


==Disposition==
==Disposition==
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*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 D/C instructions


Revision as of 22:41, 4 March 2016

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
  • 14% of people with HIV in US aren't aware of being HIV+

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

Acute Infection

  • Misdiagnosed frequently as "mono" or "flu"
  • Largest viral load, widespread dissemination of virus, and most infectious stage[2]
  • Symptoms develop 2-4wks after exposure; last for <14d

Seroconversion

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

Asymptomatic

  • Lasts for ~8yr
  • Pts may have conditions that are more common in pts w/ HIV but no indicator conditions
    • Thrush
    • Persistent vulvovaginal candidiasis
    • Peripheral neuropathy
    • Cervical dysplasia
    • Recurrent Herpes Zoster
    • ITP

AIDS

Differential Diagnosis

HIV associated conditions

  • Consider medication side effects: lactic acidosis, neuropyschiatric effects, hepatic toxicity, renal toxicity, Steven-Johnson's, cytopenias, GI symptoms, endocrine abnormalities. [4]

Diagnosis

  • Typical lab testing for HIV:
    • Screening test: ELISA
    • Confirmatory test: Western blot
  • Lactic acidosis may be seen as a side effect of many anti-retroviral medications.
  • Maintain low threshold for additional testing in setting of suspicion of opportunistic infections (OI)

Management

CDC now recommends all HIV+ individuals be started on HAART since it decreases risk of progression to AIDS and transmission risk. (Treatment should be guided and initiated by ID)

  • 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 F/U

Suggested Discharge

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

See Also

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. ↑ Serrano KD, Westergaard RP. Diagnosis and management of acute HIV in the emergency department. EM Reports, 2012:33;16.
  3. ↑ 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.
  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.
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