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}}
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==Clinical Features==
==Clinical Features==
===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
*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]]


===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]]
**[[Primary CNS lymphoma|Lymphoma]]
**MAC
**MAC
**PCP PNA
**[[PCP pneumonia]]
**PML
**[[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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==Differential Diagnosis==
==Differential Diagnosis==
{{HIV associated conditions}}
{{HIV associated conditions}}
==Evaluation==
*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 <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>
**Opt-out screening: performing the test after notifying the patient it will be performed & giving them the option to decline


==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]]


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

Revision as of 08:15, 11 July 2017

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

Acute Infection

Seroconversion

  • HIV Ab detectable 3-8wk after infection
  • 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

  • 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

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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