HIV - AIDS (main)
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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
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 Stages
Acute Infection
- Misdiagnosed frequently as "mono" or "flu"
- 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
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
Neurologic Complications
- Work-Up
- CT Head w/o contrast
- LP
- Regular studies + (India ink, viral culture, fungal culture, toxo, crypto, coccidio)
- Specific Conditions:
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
Ophthalmologic Complications
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
- HIV (Disposition)
- HIV post-exposure prophylaxis
- AIDS FUO
- AIDS Dementia
- Pneumocystis Pneumonia (PCP)
- CMV Retinitis
- Seizures in patients with HIV-AIDS
- Immune reconstitution inflammatory syndrome
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.