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Common Opportunistic Infections in HIV Patients, Part 2
Chris Farnitano, MD
Thursday, October 8, 2009
Noon Conference
Objectives
Discuss most common opportunistic infections (OIs): Dx and Rx
Discuss immune reconstitution disease Review primary OI prophylaxis
Forms
Case Study SP
27 yo male seen in clinic in June 2009 Meds: unboosted atazanavir + Truvada
since 1/09; ranitidine T cells 5; viral load 30,000 Why is his anti-HIV cocktail failing?
Case Study SP
Ritonavir added to boost atazanavir Patient instructed to take ranitidine in
AM only and antivirals in PM Blood Cx for AFB, HIV genotype
ordered
Case Study SP
Admitted to Kaiser August, 2009 with diffuse warm, tender lymphadenopathy
Biopsy performed, read as suspicious for lymphoma
Transferred to CCRMC after 7 days on clarithromycin, ethambutol, rifabutin
T Cells 209, viral load 726 What is patient’s diagnosis?
What are the most common OI’s? Cohort Studies in pre-triple therapy era:
Candida Pneumocystis Carinii Cytomegalovirus Mycobacterium Avium Complex Pneumocystis - second episode Toxoplasmi gondii Herpes zoster
Causes of death, PHC HIV clinic 2007-9
RH: Crypto meningitis TW: street drug overdose SA: sepsis, pneumonia and massive hemoptysis DW: metastatic prostate ca RP: CVA, laryngeal ca VA: PML (progressive multifocal
leukencephalopathy) AM: bacterial pneumonia, ETOH cirrhosis, wasting
OIs diagnosed, PHC HIV clinic
2005-9 PCP pneumonia Esophageal Candidiasis Herpes Simplex Herpes Zoster M. Kansasii immune reconstitution pneumonia Mycobacterium Avium Complex (MAC) Cryptococcal Fungemia, meningitis Histoplasmosis PML
Effect of HAART on Opportunistic Infection Incidence Most OI’s have declined 80-90% OI’s seen now mostly in 3 groups
undiagnosed HIV+ not in care or not adhering to therapy long time “battle-scarred warriors” failing
after a long history of multiple regimens
50-200 T Cells:
Pneumocystis Carinii Pnuemonia Toxoplasmosis Cryptococcus
Toxoplasmosis
<50 T Cells
CMV Retinitis Mycobacterium Avium Complex Cryptosporidiosis Progressive Multifocal
Leukencephalopathy
PML
Ockham's razor does not apply for advanced AIDS
-often multiple diagnoses present simultaneously ie PCP, CMV, KS, Cocci 12% of bacterial pneumonias also have
PCP 10% of PCP pneumonia complicated by
bacterial infection search for second etiology if patient not
improving
Immune reconstitution diseases(HAART attacks)
MAC adenitis CMV TB PCP
Case Study SP
Diagnosis: Immune Reconsitution MAC AFB blood culture from June grew out
MAC on 8/12 (hospital day #13)
Also: Perianal herpes Squamous cell carcinoma-in-situ, buttock Vancomycin-resistant enterococcus, groin
Primary OI prophylaxis
PCP -T cells <200 or thrush Toxo -T cells <100 and +Toxo titer MAC - Tcells <50 TB – INH x 9 months if PPD >5mm or
quantiferon-TB positive
Toxo prophylaxis
Septra SS or DS qd or DS TIW Septra Desensitisation:
1cc qd x 3d, then 2cc qd x 3d, then 5ccqd x 3d, then one SS tab qd
Dapsone 100mg qd +pyramethamine 50mg qweek + leukovorin 25mg qweek
Atovaquone 1500mg qd
MAC prophylaxis
Zithromax 600mg x 2 tabs qweek reduces infection rate 59%
Also seems to reduce risk of PCP
Cytomegalovirus Retinitis - Who Gets It? Rare above 50 T Cells Reactivation disease: most HIV patients
CMV IgG+ (90% of gay HIV+ men) 90% of CMV disease is retinitis
Cytomegalovirus Retinitis - Symptoms painless, progressive visual loss unilateral blurry vision floaters
Cytomegalovirus Retinitis - Signs coalescing white perivascular exudates surrounded by hemorrhage brushfire pattern or tomato and cheese
pizza
Cytomegalovirus Retinitis
Cytomegalovirus Retinitis
Cytomegalovirus Retinitis - Diagnosis if you suspect it, obtain ophthalmologist
confirmation within 24-48 hrs.
Cytomegalovirus Retinitis - Treatment Valgancyclovir 900mg PO BID x 21
days, then qd Adverse effects:
neutropenia ANC<500 in 15% thrombocytopenia anemia 50%: nausea, vomiting, abdominal pain or
diarrhea
Gangcyclivir intraocular implant Consider in addition to systemic
therapy: Surgically implanted depo device Effective for 6 months Replace at 6 months if still not immune
reconstituted Consider for sight threatening lesions near
the central visual field
Mycobacterium avium Complex - Who gets it? T Cells <50 screen with blood culture for AFB x 1 q
3 months to detect subclinical disease
Mycobacterium avium Complex - Symptoms fever, night sweats weight loss diarrhea
Mycobacterium avium Complex - Signs anemia Neutropenia Fever Diarrhea wasting
Mycobacterium avium Complex - Diagnosis Blood culture usually positive if symptomatic
but takes weeks to grow If need to know sooner then do bone marrow
Bx Positive sputum culture usually colonization,
not active disease Positive stool culture may be colonization, not
active disease, mucosal bx more indicative of disease
MAC-filled macrophages in spleen
Mycobacterium avium Complex - Treatment Clarithromycin 500mg BID + Ethambutol 15mg/kg/d +/- Rifabutin 300mg qd Treatment failure rate is high without
immune reconstitution drug toxicity development of resistance
Case Study SP
After 4 months of anti-MAC therapy + potent anti-HIV therapy: T Cells 71 viral load <48 Patient still hospitalized Large effusions persist Dubhoff tube required for feeding Diffuse chest/abdominal adenopathy persists MAC Cx’s show partial/complete resistance to all
MAC drugs except clofazamine Prognosis?
Forms
Summary:
Pyramid approach Prophylaxis simple: Septra and
Zithromax Rule out TB in pneumonia with T Cells
<200 Avoid treating PCP empirically An ounce of prevention pills is worth a
pound of Treatment pills
An ounce of prevention pills is worth a pound of Treatment pills