HIV - AIDS (main): Difference between revisions
No edit summary |
(addition of med side effects in ddx) |
||
| Line 62: | Line 62: | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{HIV associated conditions}} | {{HIV associated conditions}} | ||
*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. | |||
==Diagnostcally== | |||
*Lactic acidosis is a side effect of many of the anti-retroviral medications. | |||
*Should have lower threshold for labs and imaging and cultures for OIs. | |||
==Management== | ==Management== | ||
Revision as of 21:32, 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
- Fever (>90%)
- Fatigue (70-90%)
- Pharyngitis (>70%)
- Rash (40-80%)
- Headache (30-70%)
- Lymphadenopathy (40-70%)
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
- Defined as HIV + (indicator condition or CD4 < 200)
- Indicator conditions:
- Pulmonary TB
- Disseminated TB
- Invasive cervical cancer
- Esophageal candidiasis
- Cryptococcosis
- Cryptosporidiosis
- CMV Retinitis
- HSV
- Kaposi sarcoma
- Brain lymphoma
- MAC
- PCP PNA
- PML
- Brain Toxoplasmosis
- HIV Encephalitis
- HIV wasting syndrome
- Disseminated histoplasmosis
- Isosporiasis
- Recurrent Salmonella septicemia
- Recurrent Bacterial Pneumonia
Differential Diagnosis
HIV associated conditions
- HIV neurologic complications
- HIV pulmonary complications
- Ophthalmologic complications
- Other
- HAART medication side effects[3]
- HAART-induced lactic acidosis
- Neuropyschiatric effects
- Hepatic toxicity
- Renal toxicity
- Steven-Johnson's
- Cytopenias
- GI symptoms
- Endocrine abnormalities
- 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.
Diagnostcally
- Lactic acidosis is a side effect of many of the anti-retroviral medications.
- Should have lower threshold for labs and imaging and cultures for OIs.
Management
CDC now recommends all HIV+ individuals be started on HAART since it decreases risk of progression to AIDS and decreases transmission risk.
Treatment should be guided and initiated by ID
- Typical first line regimens include reverse transcriptase inhibitors (NRTI) and an integrase inhibitor
- tenofovir/emtricitabine (Truvada) and raltegravir (Isentress)
- tenofovir/emtricitabine (Truvada) and 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 tol POs/not orthostatic
- F/U arranged
- Able to comply with D/C instructions
See Also
References
- ↑ 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.
- ↑ Serrano KD, Westergaard RP. Diagnosis and management of acute HIV in the emergency department. EM Reports, 2012:33;16.
- ↑ 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.