Evaluating Common Chief Complaints in Patients with HIV

- by Brian D'Cruz

DC has highest prevalence of HIV in country: 2.5%

• but massive reduction in new cases since 2009 (incr prevalence due to aggressive screening and dx)

How to recognize HIV pateitn at Fairfax

• INOVA Junipter Clinic - treats HIV/AIDS pts

HIV Types

• HIV1 is form primary found in US
• HIV2 found in West Africa
  • slower progression
    
  • longer latent period
    
  • resistent to NNRTI's (nevirapine, efavirenz)

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Case

• young boy with malnutrition
• dx'd by clinical criteria with TB
• returned sick again, treated for MDRTB
• mother and son turned out to be HIV+

Respiratory complaints in HIV

• common is still common
• viral URI is MCC of sx
• don't assume infectious - consider cardiac etiology in pt with dyspnea
• • as HIV pts live llonger, cardiac and pulmonary disease is more prevalent
• S. pneumoniae is MCC PNA
• toxic pts need coverage for pseudomonas and possibly resistant species
• • consider Zosyn (save fluoroquinolones for future treatment)

Sinusitis

• same rules as in non-HIV pts
• be on look out for
  • aspergillus
  • mucormycosis
  • Pott's puffy tumor (osteomyelitis of the posterior sinuses and facial bones)

​Bacteremia in PNA

• Pneumococcal baceremia in up to 300x more common in HIV pts
• strongly consider blood culture prior to abx admin

PCP

• PTX in pt with low CD4 = PCP until proven otherwise
• consider checking an LDH
• hypoxemia or low A-a gradient implies need for steroids

Aspergillosis

• fungus ball in lung on XR or CT
• PTX association
• tx with amphotericin B or vorconazole
• can be found in marijuana (bake in oven at 300 degreesF for 15 mins)

Histoplasmosis

• Mississippi and Ohio River valley regions
• resembles TB
• consider sending urine antigen test in endemic regions

TB

• ALWAYS on the ddx, even with normal CD4 count
• isolate if suspected
• leader killer of HIV pts worldwide
• "2 EHRZ 4 RH"
• extrapulmonary

Respiratory Failure in HIV

• not all respiratory failure is infectious
• approx 1/5 pts with HIV and resp failure have non-infectious cause

Intubating HIV Pt

• airway lesions (Kaposi, sarcomitous lesions)
• TB
• preoxygenation
• ventilator setting
• • think of like asthma pt
  • stiff lungs
  • low rate

AMS and Headache in HIV

• common is still common (e.g. UTI)
• medication effects (hypoglycemia and otherwise)
• • isoniazid and pyridozine (B6)
• immune reconstitution syndrome in early treatment can cause AMS
• CNS lymphoma (from EBV)
• progressive multifocal leukencephalopathy (JC virus)
• AIDS dementia
• TB (again)
• get imaging (no contrast needed) and LP

Meningitis and HIV

• typica signs might be hidden due to lack of inflammatory response
• listeria is more common in HIV pts (ampicillin)
• have low threshold to do meningtis eval (LP)
• have low threshold to treat empirically
• like with every other organ system, consider syphilis and TB

Toxoplasmosis

• if you suspect, treat
• • IV Bactrim or oral pyrimethamine
  • seizures more common

Crytococcal Meningitis

• can present with just mild headache, but life-threatening
• measure opening pressure!
• • may be more sensitive than CSF cell counts (due to decreased inflammatory response)
• cryptococcal antigen test (india ink not done anymore)
• IV amphotericin + PO flucytosine - involve ID!

Sore Throat in HIV

• common is common
• oral candidiasis
• • thrush
  • angular cheilitis
  • atrophic form
  • can be scrapped off (no to be confused with hairy leukoplakia, which can't be scrapped off, but is AIDS-defining or transplant pts, cause by EBV)
  • tx: nystatin or PO fluconazole
• Candidal Esophagitis
• • MCC of esophagitis in pts with HIV
  • consider empiric fluconazole if first episode
  • (don't give PPI - removes acidic barrier to GI infections)

Diarrhea in HIV

• common is still common
• 40% of HIV pts have at least 1 episode per month
• protease inhibitors a/w diarrhea
• stool cx and O/P?
• • if you do them, do more than 1
• blood cultures
• • if you do them, do more htna 1
• if CD4 >200, additional testing less likely necessary
• teset if chronic
• consider C. diff
• empiric antiparacitics? - if story supports
• empiric antibiotics? - have lower threshold
• encourage PO fluids
• 1/4 with chronic diarrhea will not have cause identified
• resource limited considitions
• • ORS (add lime for flavor!)
  • zinc supplementation
• abdominal TB
• Kaposi sarcoma
• lymphoma
• crypto can be a/w cholestasis

Orthopedic Complaints

• common is common
• Lyme disease at Fairfax (for mon-/polyarthritis)
• HIV polymyositis
• HIV itself and protease inhibitor likely a/q osteopenia
• osteonecrosis (of femoral head particularly) is almost 50x more common in HIV
• pyoosteomyositis
• Septic Arthritis
• • MCC S. aureus
  • Lyme disease
  • TB
  • gonorrhea
  • tap joint
• Osteomyelitis
• • MCC same as gen pop
  • bacillary angiomatosis
  • • resembles KS
    • bartonella henselae
• TB
• • Pott disease (not PTTS or Pott's Puffy tumor)

Visual Complaints

• CMV retinitis
• CMV immune recovery uveitis
• herpes zoster ophthalmicus
• HIV retinopathy
• candidal endophthalmitis is not more common
• rearely - toxoplasmosis, PJP, cryptococcus

Chest Pain in HIV

• Before HAART
• • dilated cardiomyopathy
• Post-HAART
• • CAD -  at higher rate than gen pop; independent risk factor
  • • HAART meds and lipodystrophy
  • Lyme carditis
  • Chagas (Cocahabama, Boliva)
  • Pericarditis and effusions - think TB

Rashes in HIV

• peniciliosis
• bacillary angiomatosis
• SJS

General Illness

• no standard eval, depends on H7P
• consider UTI
• • consider U cx - prophylactic abx engender resistance
• anemia is common
• US: blastomycosis, histoplasmosis, coccidiomycosis
• baroadL kala azar, penicillium marneffii, vaccine preventable diseases, Chageas, malaria
• Abacavir hypersensitivity - next dose can kill them

Evaluating HIV Pt in ED

• CD4, viral load, know it