วันพุธที่ 11 กรกฎาคม พ.ศ. 2555

HIV related disease

Natural history


• Acute HIV infection (flulike or mononucleosis-like syndrome) develop 2-4 wks after exposure and last for <14 days: eg. fever, fatigue, pharyngitis, rash, headache, lymphadenopathy

• Seroconversion: 3-8 wks after infection (up to 11 mo); Incubation time in untreated patients: 8.23 yrs for adults, 1.97 yrs for children <5 years of age

• AIDS: CD4+ T-cell count <200 cells/mm3, esophageal candidiasis, cryptococcosis, cryptosporidiosis, CMV retinitis, HSV, Kaposi sarcoma, Brain lymphoma, MAC infection, PCP, PML, Brain toxoplasmosis, HIV encephalopathy, HIV wasting syndrome, Disseminated histoplasmosis, Isosporiasis, Disseminated M. TB, Recurrent Salmonella septicemia, Pulmonary TB, Recurrent bacterial pneumonia, Invasive cervical cancer

Investigation

• AntiHIV, CD4+ count, HIV viral load, CBC, electrolyte, LFTs, H/C for aerobic/anaerobic/fungal, UA, UC, serology for syphilis/cryptococcosis/toxoplasmosis/CMV infection/coccidioidomycosis

** Total lymphocyte count <1200 cells/mm3 = predictive of a CD4+ T-cell count of <200 cells/mm3 (sensitivity 62%)

• CXR

• LP if there are neurologic signs or symptoms or unexplained fever

• If clinical indicated: stool AFP

Management

• Mycobacterium avium-intracellulare: clarithromycin 500 mg PO bid + ethambutol 15 mg/kg OD + rifabutin 300 mg/kg OD

• CMV infection: ganciclovir 5 mg/kg IV bid x 2wks then 5 mg/kg/d or foscanet 90 mg/kg q 12 h x 3 wks then 90 mg/kg OD

• PCP: Trimethoprim/sulfamethoxazole 15–20 mg of trimethoprim/kg PO/IV divided doses q 8 h x 3 wk +/- prednisolone 40 mg PO bid x 5 d then 40 mg OD x 5 d then 20 mg OD x 11 d if PaO2 < 70 mmHg or A-a gradient > 35 mmHg; or pentamidine 4 mg/kg/d IV/IM x 3 wks

• Pul TB: INH 5 mg/kg OD + rifampin 10 mg/kg OD + pyrazinamide 15-30 mg/kg OD + ethambutol 15-20 mg/kg OD

• CNS Toxoplasmosis: Pyrimethamine 200 mg PO load then 50–75 mg PO OD x 6–8 wk + Sulfadiazine 1-1.5 gms PO q 6 h x 6–8 wk + Folinic acid 10 mg/d PO x 6–8 wk +/- Leucovorin 10–25 mg OD

• CNS Cryptococcosis: Amphotericin B 0.7 mg/kg IV OD x 2 wk + Flucytosine 25 mg/kg IV qid x 2 wk then Fluconazole 400 mg/d PO x 8–10 wk

• Oral thrush: clotrimazole 10 mg troches x 5 times/d or nystatin 500,000 unit x 5 times/d gargle

• Candida esophagitis: fluconazole 100-400 mg/d PO

• Salmonellosis (GI): ciprofloxacin 500 mg PO bid x 2-4 wks

• Cryptosporidiosis: HARRT

• Cutaneous HSV: acyclovir 200 mg PO x 5 times/d x 7d or famciclovir 125 mg PO bid x 7d or valacyclovir 1 gm PO bid x 7d

• Cutaneous HZV: acyclovir 800 mg PO x 5 times/d x 7-10d or famciclovir 500 mg PO tid x 7-10d or valacyclovir 1 gm PO tid x 7-10d

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