Unit 9 fever and lymphadenopathy l.jpg
This presentation is the property of its rightful owner.
Sponsored Links
1 / 44

Unit 9 Fever and Lymphadenopathy PowerPoint PPT Presentation


  • 135 Views
  • Uploaded on
  • Presentation posted in: General

Unit 9 Fever and Lymphadenopathy. Learning Objectives. Describe the differential diagnosis and evaluation of an HIV positive adult with fever Apply therapeutic options for HIV infected adults with fever Describe evaluation and management of HIV infected persons with lymphadenopathy.

Download Presentation

Unit 9 Fever and Lymphadenopathy

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Unit 9 fever and lymphadenopathy l.jpg

Unit 9

Fever and Lymphadenopathy


Learning objectives l.jpg

Learning Objectives

  • Describe the differential diagnosis and evaluation of an HIV positive adult with fever

  • Apply therapeutic options for HIV infected adults with fever

  • Describe evaluation and management of HIV infected persons with lymphadenopathy

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Definitions persistent fever l.jpg

Definitions: Persistent Fever

  • Applies to outpatient with HIV being seen by a nurse in a Level I primary care clinic

    • Temperature > 37.5°C

    • At least 2 weeks duration

    • Persistent or recurrent

    • No other significant signs/symptoms

Republic of Namibia, MoHSS Guidelines for the Clinical Management of HIV and AIDS, 2001.

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Pyrexia of unknown origin puo l.jpg

Pyrexia of Unknown Origin (PUO)

  • Phrase created in the 1960’s to describe patients with fever lasting > 3 weeks and that remains unexplained despite > 1 week of investigation in hospital

  • Now 4 categories:

    • Classical

    • HIV-associated

    • Immunosuppression-associated

    • Nosocomial

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Classic pyrexia of unknown origin l.jpg

Classic Pyrexia of Unknown Origin

IMAGINE:

Infections

Medication

Auto-immune disorders

Granulomatous conditions

Idiopathic

Neoplasia

Endocrine disorders

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Definitions hiv associated puo l.jpg

Definitions: HIV-Associated PUO

  • Applies to an HIV infected patient undergoing evaluation by a doctor for fever

  • Temperature > 38°C

  • Outpatients

    • ≥ 3 weeks duration

  • Inpatients

    • ≥ 3 days in hospital

  • No diagnosis made in this time

Source: Mandell, G.L., J.E. Bennett, R. Dolin. Principles and Practice of Infectious Disease. Sixth Edition, 2004. Elseiver, Inc. www.elseiver.com

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Hiv associated puo l.jpg

HIV-Associated PUO

  • Infections and malignancies are most common

  • Auto-immune (connective tissue) conditions are rare in patients with severe immunosuppression

  • Differential varies by CD4 cell count

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Puo conditions occurring in namibia at any cd4 count l.jpg

PUO: Conditions Occurring in Namibia At Any CD4 Count

  • Bacterial Infection

    • TB

    • Bacterial pneumonia

    • Urinary tract infection

    • Sinusitis

    • Salmonella (enteric fever)

    • Borrelia

    • Brucella

    • Intra-abdominal, intra-hepatic or other hidden abscess

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Puo conditions occurring in namibia at any cd4 count 2 l.jpg

PUO: Conditions Occurring in Namibia At Any CD4 Count (2)

  • Parasitic Infection

    • Malaria

    • Trypanosomiasis

  • Viral Infection

    • Viral hepatitis, Primary HIV infection

  • Malignancy

  • Alcoholic hepatitis

  • Drug reactions

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Hiv associated puo conditions in southern africa at low cd4 counts l.jpg

HIV-Associated PUO: Conditions in Southern Africa at Low CD4 Counts

  • CD4 < 200

    • Pneumocystis pneumonia (PCP), Kaposi’s Sarcoma, Lymphoma

  • CD4 < 100

    • Cryptococcus, Toxoplasma, Histoplasma, MOTT (M. kansasii)

  • CD4 < 50

    • MOTT (M. avium complex), Cytomegalovirus (CMV)

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Hiv associated puo study from new york city usa l.jpg

HIV-Associated PUO (Study from New York City, USA)

Source: Mandell, G.L., J.E. Bennett, R. Dolin. Principles and Practice of Infectious Disease. Sixth Edition,2004.Elseiver, Inc. www.elseiver.com

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Principles in managing hiv associated fever l.jpg

Principles in Managing HIV-Associated Fever

  • Confirm HIV infection if not already done

  • Perform clinical and laboratory staging

  • Consider local endemic infections

  • Look for focal organ involvement that can provide clues to the diagnosis

  • Provide empiric therapy if needed as the evaluation proceeds

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Persistent fever in primary care setting l.jpg

Persistent Fever in Primary Care Setting

  • Perform a history and physical exam

    • Refer severely ill patients immediately

  • Antipyretic therapy

  • Assure proper hydration

  • If no cause is apparent. Do a rapid test and treat as indicated

    • For malaria: in an endemic area during malaria season

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Empiric therapy options in primary care setting l.jpg

Empiric Therapy Options in Primary Care Setting

  • Blood smear negative and patient not on CTX prophylaxis

    • Cotrimoxazole 80/400 two tablets bd for 5 days.

    • Treats many bacterial causes

  • On CTX with respiratory symptoms

    • Amoxycillin 500 mg 8 hourly for 5 days

  • On CTX with GI symptoms or urinary tract symptoms

    • Nalidixic acid 1000 mg QID for 5 days

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


No improvement with empiric antibiotics l.jpg

No Improvement with Empiric Antibiotics

  • Refer to medical doctor for history and physical exam

  • Examinations

    • FBC

    • CD4 cell count

    • Urine dipstick

    • Blood Culture

    • Sputums for AFB

    • Malaria/Borrelia smear

    • Consider chest x-ray now if seriously ill

    • Consider stool exams in case of diarrhea

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Initial work up inconclusive l.jpg

Initial Work-up Inconclusive

  • Repeat history and physical exam

  • Retinal exam

  • Chest X-ray if not yet done

  • Liver chemistry tests

  • Consider repeat malaria/borrelia smear

  • Consider repeat blood culture, with anaerobic and mycobacterial cultures

  • Consider CSF examination

  • Consider abdominal ultrasound

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Cmv retinitis l.jpg

CMV Retinitis

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Dry season bacteremia in malawi l.jpg

Dry-Season Bacteremia in Malawi

70 (30%) of 233 adult patients with HIV admitted for fever during the dry season in Lilongwe had a positive blood culture.

Source: Archibald L et al. J Infect Dis. 2000;181:1414.

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Wet season bacteremia in malawi l.jpg

Wet-Season Bacteremia in Malawi

67 (36%) of 238 adult patients with HIV admitted for fever during the wet season in Lilongwe had a positive blood culture.

Source: Bell M et al. Int J Infect Dis. 2001;5(2):63-9.

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Abdominal ultrasound in aids l.jpg

Abdominal Ultrasound in AIDS

Comparison of results among adults referred for U/S in Congo and Zambia

Source: Tshibwabwa, ET et al. Abdominal Imaging. 2000 May-Jun;25(3):290-6.

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Do not miss common treatable conditions l.jpg

Do Not Miss Common Treatable Conditions

  • HIV-associated

    • Tuberculosis

    • Pneumocystis

    • Cryptococcosis

    • Toxoplasmosis

  • Other

    • Malaria

    • Borrelia

    • Typhoid

    • Brucellosis

    • Endocarditis, urinary tract infection, abdominal abscess

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Tuberculosis l.jpg

Tuberculosis

  • Most common cause of undiagnosed chronic fever among Namibians with HIV

  • Disseminated infection may not cause localised organ dysfunction

  • Over time, clues may emerge that can be further evaluated

    • Miliary pattern on CXR

    • Adenopathy

    • Pleural, pericardial disease

    • Meningitis

    • Infiltrative liver disease

    • Anaemia

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Tuberculosis 2 l.jpg

Tuberculosis (2)

  • Typical abnormalities in body fluids are strongly suggestive of TB (CSF, pleural, peritoneal fluid)

  • Beware: CSF may be normal in TB meningitis occurring in HIV patients

  • Ziehl-Nielson stain and cytology or histology of aspirate or biopsy (including bone marrow) may provide evidence of TB

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Tuberculosis 3 l.jpg

Tuberculosis (3)

  • A decision to give empiric treatment for TB

    • Is not just a therapeutic trial but a commitment to provide a course of therapy

    • Requires follow-up and patients who do not respond require further evaluation

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Pneumocystis pneumonia l.jpg

Pneumocystis Pneumonia

  • Some patients may not complain of dyspnea

    • Count respiratory rate at rest and with exercise

  • Chest sounds may be normal

    • Interstitial, not alveolar, disease

  • Chest x-ray may initially be normal

  • The disease is progressive without therapy, so re-evaluation will lead you to suspect the diagnosis

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Cryptococcus l.jpg

Cryptococcus

  • May present as an interstitial pneumonia before, or at the same time as, meningitis

  • Severely immunosuppressed persons often do not have meningismus

    • No stiff neck

  • May have only fever, headache, perhaps change in mental status or cranial nerve findings

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Cryptococcus 2 l.jpg

Cryptococcus (2)

  • Have a low threshold for performing a lumbar puncture

  • Always perform India ink exam on CSF

    • Request lab to send for cryptococcal Ag if India ink negative

    • In Durban 17% of AIDS patients with Cryptococcal meningitis had CSF that was normal except for the presence of yeast cells

  • Effective therapy is widely available in Namibia and underused

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Toxoplasmic encephalitis l.jpg

Toxoplasmic Encephalitis

  • May or may not be associated with fever

  • Focal neurologic deficit may be subtle

  • Progression of focal neurologic findings over days to weeks suggestive

  • Clinical response to empiric therapy is usually evident within 2 weeks

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Malaria and hiv l.jpg

Malaria and HIV

  • HIV-1 infection is associated with an increased frequency of clinical malaria and parasitaemia

  • Incidence rates of P. falciparum clinical disease increase as CD4 counts decrease

  • Genotyping shows the infections are new, and not recrudescence of previous infection

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Malaria treatment l.jpg

Malaria treatment

  • Coartem®

    • Combination tablet of

      • Artemether (20 mg) – fast acting and

      • Lumefantrine (120 mg) – slow prolonged action

  • Active against chloroquin resistant falciparum

  • Most common side effects

    • GI symptoms, headache, sleep disturbance, dizziness, myalgia or arthralgia, palpitations, cough

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Coartem l.jpg

Coartem

  • Doses are weight-banded

    • 6 doses in 3 days:

      • First dose stat, repeat in 8 hours

      • Same dose bd on days 2 and 3

    • ≥35 kg, 4 tablets/dose

  • Absorption improved if taken with food

  • Not currently approved for use in pregnant women and children < 6 months old

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Borrelia l.jpg

Borrelia

  • Tick borne relapsing fever caused by many species of Borrelia

  • 3-day long episodes of high fever with rigors and severe headache recur at 7 day intervals with splenomegaly (41%), hepatomegaly (17%) and rash (28%)

  • Spirochetes seen on blood smear

  • Tetracycline or erythromycin 500 mg 4x daily for 5-10 days

    • Doxycyline 100 mg bd for 5-10 days

    • IV penicillin/ceftriaxone for meningitis

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Typhoid and other salmonella bacteremia l.jpg

Typhoid and Other Salmonella Bacteremia

  • More common in rainy season in neighboring countries; maybe infrequent in Namibia

  • Fever without or with GI symptoms, transient rash, splenomegaly

  • Leucopaenia common, blood cultures confirm diagnosis

  • Treatment: flouroquinolones, chloramphenicol

    • Local salmonella species resistant to ampicillin and amoxycillin

    • ceftriaxone is active but rarely used for this in Namibia

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Brucellosis l.jpg

Brucellosis

  • Acquired from infected cattle and dairy products

  • Chronic fever, sweats, fatigue, pain, adenopathy (20%), hepatosplenomegaly (20-30%), epididymitis (20%), mild pancytopenia

  • Diagnosed with blood or bone marrow culture and antibody tests

  • Treatment

    • Doxycyline 200mg/d with rifampicin 600mg/d for 6 weeks

    • Doxycycline for 6 weeks with streptomycin IM daily for 2-3 wks

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Empiric therapy of bacterial infections l.jpg

Empiric Therapy of Bacterial Infections

  • Respiratory tract & Pneumonia

    • Not very sick: high dose amoxycillin, azithromycin, erythromycin, tetracycline

    • Very sick: high dose penicillin with gentamicin or cefuroxime with azithromycin

  • Meningitis

    • Ceftriaxone or high dose penicillin + chloramphenicol

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Empiric therapy of bacterial infections 2 l.jpg

Empiric Therapy of Bacterial Infections (2)

  • Skin and soft tissue (suspected S. aureus)

    • Cloxacillin, erythromycin, cephalothin

  • Bone and joint (suspected S. aureus)

    • Clindamycin or cloxacillin,

  • Urinary tract infection

    • Nitrofurantoin

    • Nalidixic acid

    • Not improving or very sick: ciprofloxacin +/- gentamicin

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Empiric therapy of bacterial infections 3 l.jpg

Empiric Therapy of Bacterial Infections (3)

  • Bacillary dysentery

    • Nalidixic acid, ciprofloxacin

    • Metronidazole if amebiasis or C. difficile suspected

  • Intra-abdominal abdominal abscess or peritonitis

    • Ampicillin, gentamicin, metronidazole

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Empiric therapy of bacterial infections 4 l.jpg

Empiric Therapy of Bacterial Infections (4)

  • Endocarditis

    • Native valve: penicillin and gentamicin

    • Drug injector: ciprofloxacin or cephalothin + gentamicin

  • Sepsis or bacteremia

    • Ampicillin and gentamicin

      OR

    • Cefuroxime and gentamicin

  • Neutropenic fever

    • Pipiracillin/tazobactam with gentamicin

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Generalised lymphadenopathy differential diagnosis l.jpg

Generalised Lymphadenopathy: Differential Diagnosis

  • Acute Retroviral Syndrome

  • HIV associated Persistent Generalised Lymphadenopathy

    • not a febrile illness

  • Secondary syphilis

  • EBV or CMV viral infection

  • Autoimmune disease

    • Unusual in immunosuppressed patients

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Localised lymphadenopathy differential diagnosis l.jpg

Localised Lymphadenopathy: Differential Diagnosis

  • Acute Bacterial Infection

    • Nodes draining a localised bacterial infection

  • Sexually Transmitted Infection

    • Chancroid

    • Lymphogranuloma venereum

  • Chronic Infection

    • Tuberculosis, MOTT

    • Histoplasma

    • Immune Response Inflammatory Syndrome

  • Cancer

    • Lymphoma

    • Kaposi’s Sarcoma

    • Metastases

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Localised adenopathy l.jpg

Localised Adenopathy

  • Evaluation of localised adenopathy not due to a local draining infection (pharynx, skin, limb), STI, or obvious KS

    • Needle aspiration of suppurating node for drainage and diagnosis

      • Rarely surgical drainage is needed

    • Needle aspiration for cytology and AFB smear

    • Biopsy

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Yield of needle aspiration for diagnosis hiv related lymphadenopathy zambia l.jpg

Yield of Needle Aspiration for Diagnosis: HIV-Related Lymphadenopathy - Zambia

Source: Patil and Bern. Journal of Clinical Pathology 1993;46:806-9.

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Key points fever l.jpg

Key Points: Fever

  • First rule-out malaria

  • Attempt antibacterial empiric therapy

  • Tuberculosis is the most common cause (but not the only cause) of pyrexia of unknown origin in HIV+ patients in Southern Africa

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


Key points adenopathy l.jpg

Key Points: Adenopathy

  • Generalised adenopathy may be Primary HIV, PGL, another viral infection, secondary syphilis, or an auto-immune disease

  • Localised adenopathy usually has a specific cause and needs to be fully evaluated

Training on Clinical Care of HIV, AIDS and Opportunistic Infections


  • Login