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HIV

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  1. HIV Group B2

  2. Objectives • Diagnosis of HIV • Screening of chronic infections in AIDS patients • Immunizations for AIDS patients • Board review questions

  3. Diagnosis of HIV

  4. Diagnosis of HIV • Presumptive diagnosis made with ELISA • Sensitive, used to Rule Out disease • Positive Results are confirmed with Western Blot assay • Western Blot Assay: • Specific, used to Rule Indisease • False Negatives : people with early HIV infection often have negative test results • Window Period: time from HIV infection and the appearance of anti-HIV antibodies that can be measured. (3-12 weeks for seroconversion) • Diagnosis of Acute HIV • RT-PCR (HIV RNA), PCR (HIV DNA), p24 antigen detection

  5. Neonatal Infection: • Because of the persistence of the maternal HIV antibody, infants younger than 18 months require virologic assays that directly detect HIV in order to diagnose HIV infection • Maternal antibody confounds diagnosis (anti-gp120 crosses placenta) • Diagnosis of HIV infection • Preferred virologic assays include HIV DNA PCR and HIV RNA assays • Two or more negative results separated by at least one month is considered a negative result • HIV p24 antigen assay for infant diagnosis is NOT recommended because the sensitivity and specificity of the assay in the first months of life is less than that of other HIV virologic tests.

  6. HIV – Chronic Disease Screen

  7. Cytomegalovirus CRIBS • DNA Enveloped Virus • Similar to Herpes Virus • Epidemiology • 80% seropositive by adulthood • Pathology • In Utero Infection • Heterophil-negative mononucleosis • Giant cells • Immunocompromised • Systemic CMV Inclusion Disease • Latency • Treatment • Gangiclovir

  8. Toxoplasmagondii CRIBS • Lifecycle • Definitive host is cat • Humans secondarily infected • Human Disease • Inhibited by cellular immunity • Can cross placenta • Immunocompromised • Encephalopathy • Treatment • Sulfadiazem + pyrimethamine

  9. Tuberculosis CRIBS • Mycobacterium tuberculosis • Obligate aerobe • Acid fast • Chord factor = virulence • Epidemiology • Most common microbial killer • 90% of infections are asymptomatic • Pathology • Exudative Lesions vs Tubercle • Ghon complex • Clinical manifestation • Bloody sputum is most common sign of acute or reactivated infection • Cough, weight loss, fatigue, malaise • Disseminated • GI or Hematogenous • Immunocompromised at increased risk • Milliary TB • Potts Disease • Treatment • Immunocompetant/non-MDR • Pyrazinamde (2 mo) + Isoniazid (6 mo) + ( Rifampin (6 mo) • Immunocompromised/MDR • Pyrazinamde (+ Isoniazid + Rifampiin • + Ethambutol • All for 9-12 mo • Adherence is of utmost importance • Liver enzyme assays • Alcohol abstenance

  10. HIV – Chronic Disease Screen

  11. Hepatitis B virus • DNA Virus • Hepadnavirus, transmitted by parenteral, sexual, and maternal fecal routes. • Epidemiology • 70-90% of HIV-infected individuals in the United States • Pathology • Replicate in liver cell which cause Cytotoxic T Lymphocytes to produce antiviral cytokines damage liver • Chronic form of hepatitis • Impact of HIV on the Course of HBV Infection • All HIV-infected individuals should be screened for HBV coinfection with HBsAg testing. • HIV and chronic HBV coinfection have higher levels of HBV DNA and lower rates of clearance of the hepatitis B e antigen • Patients who do not have evidence of HBsAg should have HBcAb and HBsAb evaluated to assess for prior HBV infection as well as HBsAb, which provides evidence of immunologic control of prior infection or vaccination. • Management • Interferon, Lamuvidine, Entecaviretc

  12. Gonorrhea/Chlamydiae • Gonorrhea • Gram negative cocci • No polysaccharide capsule • No maltose fermentation • Epidemiology • The second most common bacterial sexually transmitted infection • Pathology • Gonorrhea, septic arthritis, PID • Neonatal conjunctivitis, Fitz-Hugh-Curtis syndrome • HIV link • Five times more likely than uninfected individuals to acquire HIV • Dx • Gram stain, culture, and PCR • Screening • All sexually active women younger than 25 years by serology • Chlamydiae • Obligate intracellular organism • Elementary body & Reticulate body • C. trachomatis & C. pneumoniae • Epidemiology • The most common bacterial sexually transmitted infection • Pathology • Artrithis, urethritis, conjunctivitis, PID • Atypical pneumoniae • HIV link • Two to five times more likely than uninfected individuals to acquire HIV • Screening • Nucleic acid amplification tests (NAATs) can identify chlamydial infection in asymptomatic women

  13. Syphilis • TrepanomaPallidum • Gram negative spiral shaped • Epidemiology • Over 36,000 cases of syphilis in 2006 in U.S. • Pathology • 1˚ syphilis • Painless chancre • 2˚ syphilis • Systemic symptoms with condylomatalata and maculopapular rash • 3˚ syphilis • Gummas, aortitis, neuroshyphilis, Argyll Robertson pupil • HIV link • Syphilis increases the risk of HIV transmission by two to five times and co-infection is common (30–60% in a number of urban centers) • Screening • Blood test • venereal disease research laboratory VDRL) and rapid plasma reagintests • treponemalpallidum particle agglutination (TPHA) or fluorescent treponemal antibody absorption test (FTA-Abs) • Treatment • Penicillin G

  14. Recommended Vaccines for AllHIV Patients Immunization Name • HBV • Influenza • Polysaccharide Pneumococcal • Tetanus & DiptheriaToxoid (Td) • Tetanus, Diptheria, & Pertussis (Tdap) Cause • Hepatitis B • Flu • Pneumonia • Lockjaw and Diptheria • Lockjaw, diptheria, pertussis

  15. Factoids 1. HBV • Give unless there is evidence of Hep B. Check blood HBC Ab levels after immunizaiton • 3 shots over 6 months. Can give additional • 2. Influenza • -Give every year. Only injectable (not nasal) • -1 shot/yr

  16. 3. Polysaccharide Pneumococcal -Give soon after HIV diagnosis - If CD4 < 200cell/mm3, repeat immunization when count is above 200cell/mm3 4. Tetanus & Diptheria (Td) -1 shot every 10 years 5. Tetanus, Diptheria, & Pertussis (Tdap) -Give as booster in place of Td in pts 64 yrs or younger

  17. Recommended for SOMEHIV patients • Hepatitis A virus (HAV) • Hepatitis A/Hepatitis B combined vaccine (Twinrix) • Haemophilus influenza type B • Human Papillomavirus • Measles, Mumps, Rubella • Meningococcal • Varicella

  18. Board Question • Which of the following immunologic assays employs separation of proteins by electrophoresis in polyacrylamide gels and subsequent transfer to nitrocellulose gels, followed by reaction with antibodies? • Complement Fixation • ELISA • Immunoelectrophoresis • Indirect fluorescent antibody test • Western Blot

  19. Board Question • Which of the following immunologic assays employs separation of proteins by electrophoresis in polyacrylamide gels and subsequent transfer to nitrocellulose gels, followed by reaction with antibodies? • Complement Fixation • ELISA • Immunoelectrophoresis • Indirect fluorescent antibody test • Western Blot

  20. Board Question CRIBS An HIV pt presents to your outpatient IM clinic and your preceptor asks you to examine the patient. The patient complains of general fatigue and has swollen cervical lymph nodes and you note he has not been compliant with his HAART therapy. Being a good osteopathic medical student you perform a fundoscopic exam looking for retinal lesions due to: a. Uncontrolled diabetes b. CMV infection c. Disseminated Tuberculosis d. As part of the physical exam you perform on all your patients because you want to look good for when you rotate with Dr. Stewart e. You remembered hearing about link between HIV and retinal problems during CRIBS even while you were busy attending every guest lecturer and studying for boards

  21. Board Question CRIBS An HIV pt presents to your outpatient IM clinic and your preceptor asks you to examine the patient. The patient complains of general fatigue and has swollen cervical lymph nodes and you note he has not been compliant with his HAART therapy. Being a good osteopathic medical student you perform a fundoscopic exam looking for retinal lesions due to: a. Uncontrolled diabetes b. CMV infection c. Disseminated Tuberculosis d. As part of the physical exam you perform on all your patients because you want to look good for when you rotate with Dr. Stewart e. You remembered hearing about link between HIV and retinal problems during CRIBS even while you were busy attending every guest lecturer and studying for boards

  22. Board Question A 65 y/o man with a hx of viral hepatitis presents to physician with complaints of early satiety, 10 lb weight loss over three months, upper abdominal pain, and yellowing of his eyes. The patient states he lived in NY for his entire life, has not traveled outside of the country, and received two blood transfussion in early 1970’s following MVA. Work up reveals extensive macronodular cirrhosis with 2x2 xm mass in his liver. Which of the following viral infections is most likely to result in this patient’s current presentation? a. CMV b. Hep A c. Hep C d. Hep E e. HIV

  23. Board Question A 65 y/o man with a hx of viral hepatitis presents to physician with complaints of early satiety, 10 lb weight loss over three months, upper abdominal pain, and yellowing of his eyes. The patient states he lived in NY for his entire life, has not traveled outside of the country, and received two blood transfussion in early 1970’s following MVA. Work up reveals extensive macronodular cirrhosis with 2x2 xm mass in his liver. Which of the following viral infections is most likely to result in this patient’s current presentation? a. CMV b. Hep A c. Hep C d. Hep E e. HIV

  24. Board Question • If an patient has been diagnosed with HIV, which of the following immunizations would be the least important to be administered: A. Tetanus and Diptheria B. Human Papillomavirus C. Hepatitis B D. Influenza E. Polysaccharide Pneumococcal

  25. Board Question • If an patient has been diagnosed with HIV, which of the following immunizations would be the least important to be administered: A. Tetanus and Diptheria B. Human Papillomavirus C. Hepatitis B D. Influenza E. Polysaccharide Pneumococcal

  26. Board Question • Each of the following statements concerning the fluorescent treponemal antibody-absorbed (FTA-ABS) test for syphilis is correct EXCEPT: A. The test is specific for TreponemapallidumB. The patient's serum is absorbed with saprophytic treponemesC. Once positive, the test remains so despite adequate therapyD. The test is rarely positive in primary syphilis E. It is a diagnostic test not a screening test

  27. Board Question • Each of the following statements concerning the fluorescent treponemal antibody-absorbed (FTA-ABS) test for syphilis is correct EXCEPT: A. The test is specific for TreponemapallidumB. The patient's serum is absorbed with saprophytic treponemesC. Once positive, the test remains so despite adequate therapyD. The test is rarely positive in primary syphilis E. It is a diagnostic test not a screening test