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Evaluating Common Chief Complaints in Patients with HIV

7/20/2016

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Picture
- 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)



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
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  • Clinical
    • Discharge Macros
    • Procedure Macros
    • Exam Macros
    • Pediatric Macros
    • Antibiogram
    • Follow Up
    • 2023 MDM
    • Heart Pathway
    • Jeromy's Macros
  • Education
    • EM Education
    • Critical Care
    • FOAM
  • Orientation
    • Dept Orientation
    • Cerner
    • Dragon
  • Links
    • Clinical Links
    • StatMacros
    • ICU Bootcamp
  • Private
    • MCS
    • GWU Contacts & Map