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
- Approximately 1.2 million people in the US are living with HIV [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
- Misdiagnosed frequently as "mononucleosis" or "flu"
- Largest viral load, widespread dissemination of virus, and most infectious stage[3]
- Symptoms develop 2-4wks after exposure; last for <14d
- Fever (>90%)
- Fatigue (70-90%)
- Pharyngitis (>70%)
- Rash (40-80%) - Pruritic papular eruption of HIV
- Headache (30-70%)
- Lymphadenopathy (40-70%)
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
- Thrush
- Persistent candidia vaginitis
- Peripheral neuropathy
- Cervical dysplasia
- Recurrent Herpes Zoster
- ITP
- Unexplained weight loss
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
- Pruritic papular eruption of HIV
- Lymphoma
- MAC
- PCP pneumonia
- Progressive multifocal leukoencephalopathy
- 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[4]
- HAART-induced lactic acidosis
- Neuropyschiatric effects
- Hepatic toxicity
- Renal toxicity
- Steven-Johnson's
- Cytopenias
- GI symptoms
- Endocrine abnormalities
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
External Links
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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. https://aidsinfo.nih.gov/guidelines Accessed 03/04/16