HIV
This is the USPSTF recommendation for HIV screening for normal risk persons.
What is one-time screening between the ages of 15 and 65?
And during each pregnancy!
Repeat for persons at high risk.
This is the meaning behind the "U=U" saying regarding HIV PREP.
What is "Undectable equals Untransmittable"?
Meaning that people with HIV who achieve and maintain an undectable viral load cannot sexually transmit HIV to their partners. It emphasizes the effectiveness of modern ART.
HIV/AIDS patients meeting this criteria and non-HIV/AIDS patients who fall into this other category are at risk of PML.
Name any second condition that puts patients at risk for PML as well.
What is HIV/AIDS patients with CD4 <200/uL and patients with hematologic malignancies, solid organ transplant, autoimmune disorders, or immunomodulatory therapy (e.g. natalizumab, efalizumab)?
This is the first line treatment for mild to moderate PJP.
What is oral bactrim?
Moderate to severe disease is treated with IV bactrim plus glucorticoids.
Patients with CD4 counts below this threshold are at higher risk for infection with disseminated cryptococcal disease.
What is CD4 <100/uL?
This is the recommended initial HIV test.
What is an HIV-1/2 antigen/antibody combination immunoassay?
Highly sensitive and specific. If (+) proceed with HIV-1/HIV-2 antibody differentiation immunoassay.
This is the most commonly recommended PREP regimen for patients without renal or bone disease as it is the most widely studied regimen among various populations and can reduce the risk of sexual HIV transmission by nearly 100%.
What is tenofovir disoproxil fumarate-emtricitabine (TDF-FTC AKA Truvada) once daily?
Alternative is TAF-FTC (AKA Descovy) as an alternative for MSM if there is mildly reduced renal function (GFR 30-60) or with/at-risk-for bone disease.
Apretude (cabotegravir) is a long-acting injectable option for concerns of daily compliance or renal/bone disease.
PML is caused by reactivation of this entity.
What is JC polyomavirus?
Toxoplasmosis typically presents with this imaging finding in a patient with HIV/AIDS and this CD4 count.
What is multiple ring-enhancing brain lesions and CD4 count <100/uL?
This is the preferred induction therapy for cryptococcal meningitis.
What is liposomal amphotericin B (IV) plus flucytosine?
Duration >= 2 weeks. Intrathecal amphotericin is just for coccidioidal meningitis.
Extensive expansion of these two otherwise less severe dermatologic manifestations are concerning for underlying HIV/AIDS infection.
What are psoriasis and seborrheic dermatitis?
Consideration should be given to recurrent zoster as well.
This is the appropriate timeline to initiate antiretroviral therapy in a patient with confirmed HIV.
What is within 7 days of confirmed diagnosis (AKA Rapid ART) regardless of CD4 count?
Commonly used regimens include biktarvy (bictegravir-emtricitabine-tenofovir alafenamide), tivicay (dolutegravir) + truvada (tenofovir disoproxil fumarate-emtricitabine), or cabotegravir+rilpivirine (cabenuva, long-acting injectable).
These are the diagnostic tests for PML.
It's an algorithm, if step 1 is positive, proceed to step 2.
What is MRI brain with and without gadolinium followed by CSF JCV PCR testing if positive?
High signal intensity cerebral gray-white junction or brainstem white matter lesions on T2 or FLAIR images, +- enhancement +- mild mass effect is considered positive.
This is a typical history presentation of PJP.
Name at least 3 symptoms and the appropriate timeline.
What is an HIV or immunocompromised host with subacute presentation of:
nonproductive cough, dyspnea, hypoxia with exercise and systemic symptoms like fever/chills/sweats, and weight loss.
Physical exam findings include tachypnea, diffuse rales, or spontaneous pneumothorax (so have high suspicion!).
Initial therapy for candidemia should involve one of these medications.
What is anidulafungin, caspofungin, or micafungin?
CNS or ocular infections require amphotericin B or an azole 2/2 poor CNS/eye penetration of echinocandins.
These are the diagnostic criteria for AIDS.
What are CD4 <200 and presence of an AIDS-defining illness?
This is the preferred treatment regimen for most patients for non-occupational post exposure prophylaxis (nPEP).
What is TDF-FTC plus dolutegravir?
Can also consider TAF-FTC plus dolutegravir or bictegravir-emtricitabine-tenofovir alafenamide (AKA Biktarvy). Biktarvy can be used off-label alone.
A 28-day course is recommended, although optimal duration is not known. HIV testing should be done at 4-6 weeks and 3 months post exposure.
This is the treatment for PML.
What is treat the underlying condition or discontinue immunomodulatory therapy if present?
No disease-specific treatment.
Either of these two agents can be used as PJP prophylaxis if bactrim is contraindicated.
Name both.
What are dapsone or atovaquone?
Treatment is not indicated for Candida "infection" in these 2 cases.
What is Candida isolated from sputum in mechanically ventilated patients or in asymptomatic candiduria (except if neutropenic or undergoing invasive procedures)?
These are 3 opportunistic or AIDS-defining illnesses (besides PML, PJP, toxoplasmosis, cryptococcal disease, and esophageal candidiasis because they're in the titles of the categories).
What are (per:
recurrent bacterial infections, coccidioidomycosis/histoplasmosis (disseminated/extrapulmonary), CMV (retinitis, esophagitis, colitis), HIV-related encephalopathy, HSV (bronchitis, pneumonitis, esophagitis), kaposi sarcoma (HHV8), burkitt lymphoma, TB or MAC (disseminated/extrapulmonary), HIV-related wasting syndrome
?
IDSA also lists leishmaniasis, malaria, microsporidosis, syphilis, talaromycosis, bartonellosis, chagas disease, Hep B/C, and HPV.
For patients with CKD 4 or worse not on dialysis, this is the recommended regimen for HIV treatment in otherwise treatment naive persons.
Assuming the patient has a no evidence of resistance, no evidence of chronic HBV, and must have a viral load <500k copies/mL.
What is dolutegravir plus lamivudine?
AKA Dovato
For patients with HIV/AIDS who develop PML, they are at risk for a condition known as PML-IRIS (immune reconstitution inflammatory syndrome), and this is the appropriate treatment.
What is continue ART and add high-dose glucocorticoids?
This is the correct duration of treatment for a patient with active Toxoplasmosis.
What is until asymptomatic and immune reconstitution (i.e. CD4 >200) is present for 6 months.
These are 3 risk factors for invasive candida infection.
What are:
reduced cell-mediated immunity
exposure to broad-spectrum antibiotics
kidney failure
GI surgery
Prolonged ICU stay
Parenteral nutrition
?