Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine (91 page)

•
ARVs should be given in consultation w/ HIV specialist
(
JAMA
2010;304:321) • Counseling re: strict adherence to ARVs is essential; genotype prior to ART-initiation •
All
HIV
Pts should be considered for ARVs; strongly recommended initiate Rx for:

AIDS-defining illness
, pregnancy, HIV-assoc. nephropathy, HCV/HBV co-infxn

CD4 £500/mm
³
(
NEJM
2009;360:1815 & 2011;365:193; DHHS 2012;
http://aidsinfo.nih.gov
)

Consider if CD4 >500; depends on Rx toxicity, adherence, potential for transmission

• Regimens for treatment-naïve Pts (DHHS guidelines Mar 29, 2012;
http://aidsinfo.nih.gov
)

[NNRTI + 2 NRTI]
or
[PI (± low-dose ritonavir) + 2 NRTI] or [II + 2 NRTI]

• Initiation of ARVs may
transiently worsen
existing OIs for several wks due to immune reconstitution inflammatory syndrome (IRIS)
Approach to previously established HIV
Pt

•
H&P
(mucocutaneous, neurocognitive, OIs, malignancies, STDs); meds •
Review ARVs
(past and current); if any must be interrupted,
stop all
to ↓ risk of resistance • Failing regimen = unable to achieve undetectable viral load, ↑ viral load, ↓ CD4 count or clinical deterioration (with detectable viral load consider genotypic or phenotypic assay)

COMPLICATIONS OF HIV/AIDS

Fever

• Etiologies (
Infect Dis Clin North Am
2007;21:1013)

infxn (82–90%)
:
MAC
,
TB
,
CMV
,
early PCP
,
Histo
,
Crypto
,
Coccidio
,
Toxo
, endocarditis

noninfectious
:
lymphoma
,
drug reaction.
Non 1° HIV itself rarely (<5%) cause of fever.

• Workup: guided by CD4 count, s/s, epi, & exposures

CBC, chem, LFTs, BCx, CXR, UA, mycobact. & fungal cx, ✓ meds, ? ✓ chest & abd CT

CD4 <100–200 → serum crypto Ag, LP, urinary
Histo
Ag, CMV PCR or antigenemia

pulmonary s/s → CXR; ABG; sputum for bacterial cx, PCP, AFB; bronchoscopy

diarrhea → stool for fecal leuks, culture, O&P, AFB; endoscopy

abnormal LFTs → abd CT, liver bx (for pathology and culture)

cytopenias → BM bx (include aspirate for culture)

Cutaneous

• Seborrheic dermatitis; eosinophilic folliculitis;
warts
(HPV); HSV & VZV; MRSA skin & soft tissue infxns; scabies; candidiasis; eczema; prurigo nodularis; psoriasis; drug eruptions • Dermatophyte infx: prox subungual onychomycosis (at nail bed); pathognomonic for HIV

•
Molluscum contagiosum
(poxvirus): 2–5 mm pearly papules w/ central umbilication •
Kaposi’s sarcoma
(KSHV or HHV8): red-purple nonblanching nodular lesions •
Bacillary angiomatosis
(disseminated
Bartonella
): friable violaceous vascular papules
Ophthalmologic

•
CMV retinitis
(CD4 usu <50); Rx: gan-or valganciclovir, ganciclovir implant or cidofovir • HZV, VZV, syphilis (at any CD4 count) or
Toxo
: CD4 usually <100

Oral

•
Aphthous ulcers; KS; thrush
(oral candidiasis): curd-like patches typically w/ burning or pain;
oral hairy leukoplakia
: painless proliferation of papillae w/ adherent white coating usually on lateral tongue, caused by EBV but not precancerous
Endocrine/metabolic

•
Hypogonadism
; adrenal insufficiency (CMV, MAC, TB, HIV or med-related); wasting osteopenia/porosis (at all CD4 counts); fragility fractures •
Lipodystrophy
: central obesity, peripheral lipoatrophy, dyslipidemia, hyperglycemia • Lactic acidosis: N/V, abd pain; ? mitochondrial toxicity of AZT, d4T, ddI, other NRTI
Cardiac
(
JACC
2013;61:511)

• Dilated CMP (10–20%); PHT; CVD (
NEJM
2003;348:702); pericarditis/effusion, VTE

Pulmonary

•
Pneumocystis jiroveci
(PCP) pneumonia (CD4 <200)
(
NEJM
1990;323:1444)

constitutional sx, fever, night sweats, dyspnea on exertion, nonproductive cough

CXR w/ interstitial pattern, ↓ P
_a
O
₂
, ↑ A-a ∇, ↑ LDH,
PCP sputum stain,
β-glucan

Rx if P
_a
O
₂
>70:
TMP-SMX
15–20 mg of TMP/kg divided tid, avg dose = DS 2 tabs PO tid

Rx if P
_a
O
₂
<70 or A-a gradient >35:
prednisone
before abx (40 mg PO bid; ↓ after 5 d) Alternative Rx if sulfa-allergy or renal insufficiency