HIV

TMP-SMX for 21 days - Pt most likely has infection w/ P.jiroveci - A) Signs/Symptoms ---1) Dyspnea, ---2) Fever, ---3) Non-productive cough, ---4) Tachypnea & impaired oxygenation --------(indicated on an arterial blood gas sample, or evidenced by cyanosis on examination) ---5) Lung auscultation -------a) diffuse bilateral rhonchi ---6) CXR -------a) Diffuse bilateral interstitial pattern with ground-glass opacities. -B) MGMT ---1) TMP-SMX for 21 days → FIRST LINE ---2) TMP-SMX for 21 days + prednisone taper ------(Prednisone should be initiated only in patients with marked hypoxemia) ----------a) PaO2 <70 mmHg OR ----------b) A-a gradient >30) --------------[Pt has PaO2 of 75 & A-a of 20]

(Q 1/2) A 33-year-old woman presents to the Emergency Department with complaints of progressive shortness of breath for the past several days. She has also had a dry cough and low-grade fevers during this time. Three years ago, she had one episode of severe staphylococcal pneumonia with abscess formation requiring intubation for a period of two weeks, at which time the diagnosis of HIV infection was also made. She was initiated on highly active anti-retroviral therapy at that time and has been maintained on a multidrug regimen ever since. She has no known drug allergies and is taking no other medications. Her last tuberculin skin test (PPD) was negative with 3mm of induration. Her temperature is 38.4°C (101.0°F), respirations are 22/minute, SpO2 is 92%. She is not in respiratory distress, and there are diffuse bilateral rhonchi on auscultation of the lung fields. An ABG shows a PaO2 of 75 mm Hg and an A-a gradient of 20 mmHg. A chest x-ray reveals diffuse bilateral interstitial infiltrates. Which of the following is the most appropriate TMT? (TMP-SMX for 21 days VS TMP-SMX for 21 days + prednisone tape)

CNS lymphoma - Pt has a positive PCR for EBV - EBV is associated w/: ---1) CNS lymphoma (non-Hodgkins lymphoma) -------(especially in AIDS pts) Progressive multifocal leukoencephalopathy - Associated w/ JC virus - However, key differences are: ---1) DOES NOT CAUSE RING-ENHANCING lesions ------(pt would have DISSEMINATED lesions on MRI)

(Q 1/2) A 52-year-old man is brought to the emergency department because of headaches, vertigo, and changes to his personality for the past few weeks. He was diagnosed with HIV 14 years ago and was started on antiretroviral therapy at that time. Medical records from one month ago indicate that he followed his medication schedule inconsistently. Since then, he has been regularly taking his antiretroviral medications and trimethoprim-sulfamethoxazole. His vital signs are within normal limits. Neurological examination shows ataxia and apathy. Mini-Mental State Examination score is 15/30. Laboratory studies show: - Hb-------------------------------12.5 - Leukocytes----------------------8,4K - Segmented neutrophils---------80% - Eosinos---------------------------1% - Lymphos-------------------------17% - Monocytes-----------------------2% - CD4+ Ct--------------------------90 - PLTS-----------------------------328K An MRI of the brain with contrast shows a solitary ring-enhancing lesion involving the corpus callosum and measuring 4.5 cm in diameter. A lumbar puncture with subsequent cerebrospinal fluid analysis shows slight pleocytosis, and PCR is positive for Epstein-Barr virus DNA. Which of the following is the most likely diagnosis? (CNS lymphoma VS Progressive multifocal leukoencephalopathy)

Methotrexate -A) MGMT for Primary CNS lymphoma ---1) TMT ------a) Methotrexate → (DOC) ------b) Cytarabine/Temozolomide ---------(in pts w/ renal insufficiency; GFR < 30) Surgical resection - Not used in TMT for primary CNS lymphoma b/c most lesions are multifocal, deep-seated tumors that do not have a distinct capsule

(Q 2/2) The patient is admitted to the hospital. A stereotactic brain biopsy of the suspicious lesion is performed that shows many large lymphocytes with irregular nuclei. Which of the following is the most appropriate treatment? (Methotrexate VS Surgical resection)

Toxo & histo - Pt presents w/ a CD4+ of 90 -A) Organism susceptibility at CD4+ 50-100 include: ---1) Toxo ---2) Coccidioidomycosis ---3) Cryptosporidiosis ---4) Histoplasmosis Toxo & cryptococcosis - At CD4+ Ct of 90 the pt is susceptible to a cryptococcus organism - However, the disease this pt is susceptible to is Cryptosporidiosis ----(not cryptococcosis) Toxo, CNS lymphoma, & CMV retinitis - Seen in HIV pts w/ CD4+ Ct < 50

(Q 2/3) A 33-year-old woman presents to the Emergency Department with complaints of progressive shortness of breath for the past several days. She has also had a dry cough and low-grade fevers during this time. Three years ago, she had one episode of severe staphylococcal pneumonia with abscess formation requiring intubation for a period of two weeks, at which time the diagnosis of HIV infection was also made. She was initiated on highly active anti-retroviral therapy at that time and has been maintained on a multidrug regimen ever since. She has no known drug allergies and is taking no other medications. Her last tuberculin skin test (PPD) was negative with 3mm of induration. Her temperature is 38.4°C (101.0°F), respirations are 22/minute, SpO2 is 92%. She is not in respiratory distress, and there are diffuse bilateral rhonchi on auscultation of the lung fields. An ABG shows a PaO2 of 75 mm Hg and an A-a gradient of 20 mmHg. A chest x-ray reveals diffuse bilateral interstitial infiltrates.The patient begins a 21-day course of TMP-SMX and is restarted on antiretroviral therapy. At the time of admission, her CD4+ count is 90 cells/mm3. Six months ago it was 400 cells/mm3. In addition to Pneumocystis jirovecii pneumonia, to which of the following infections or diseases is this patient also highly susceptible? (Toxo & histo VS Toxo & cryptococcosis VS Toxo CNS lymphoma, & CMV retinitis)

TMP-SMX (single strength) only - TMP-SMX is used for PCP prophylaxis -----(TMP-SMX is used to Toxo prophylaxis) -A) Indications for prophylaxis for PCP are: ---1) CD4+ < 200 mm3; prior PCP -------(Discontinue when CD4+ count > 200 mm3 for at least 3 months) TMP-SMX (single strength), AZ weekly - AZ is used for MAC prophylaxis -A) indications for MAC prophylaxis are: ---1) CD4 < 50/mm3 -----(Discontinue prophylaxis when CD4 + >100/mm3 for at least 6 months) TMP-SMX (single strength), AZ weekly, Isoniazid X's 9 months - Isoniazid is used for TB prophylaxis -A) Indications for TB prophylaxis are: ---1) PPD > 5/mm3 ------[Pts PPD is 3/mm3]

(Q 3/3) A 33-year-old woman presents to the Emergency Department with complaints of progressive shortness of breath for the past several days. She has also had a dry cough and low-grade fevers during this time. Three years ago, she had one episode of severe staphylococcal pneumonia with abscess formation requiring intubation for a period of two weeks, at which time the diagnosis of HIV infection was also made. She was initiated on highly active anti-retroviral therapy at that time and has been maintained on a multidrug regimen ever since. She has no known drug allergies and is taking no other medications. Her last tuberculin skin test (PPD) was negative with 3mm of induration. Her temperature is 38.4°C (101.0°F), respirations are 22/minute, SpO2 is 92%. She is not in respiratory distress, and there are diffuse bilateral rhonchi on auscultation of the lung fields. An ABG shows a PaO2 of 75 mm Hg and an A-a gradient of 20 mmHg. A chest x-ray reveals diffuse bilateral interstitial infiltrates. The patient completes a 21-day course of trimethoprim sulfamethoxazole for Pneumocystis jirovecii pneumonia and returns to clinic for follow-up. Her current CD4+ count is 115/mm3. A tuberculin skin test was non-reactive one year ago, today the PPD reveals 2 mm of induration, and she has no known exposures. Serology for Toxoplasma gondii is negative. She received annual influenza vaccine and pneumovax during her hospitalization. What is/are the next appropriate step(s) in the management of this patient? (TMP-SMX (single strength) only VS TMP-SMX (single strength), AZ weekly VS TMP-SMX (single strength), AZ weekly, Isoniazid X's 9 months)

TMP-SMX - Pts w/ a Hx of transplant & that are immunocompromised should be given TMP-SMX for prophylaxis Azithromycin - This is used for prophylaxis against MAC in HIV patients w/ CD4+ <50

A 50-year-old man has a kidney transplantation for end-stage renal disease in the setting of long-standing polycystic kidney disease. His postoperative course is uncomplicated. He had smoked one pack of cigarettes daily for 20 years but quit 5 years ago. He does not drink alcohol or use illicit drugs. Current medications include basiliximab, mycophenolate mofetil, and prednisone. His vital signs are within normal limits. On physical examination, the surgical incisions appear clean and intact. Prior to discharge, administration of which of the following is most appropriate in this patient? (Azithromycin OR TMP-SMX)

Hep A, MMR, & Varicella - Normally, Pt should receive MMR & Varicella at 12 months - This pt has HIV, however he has a NORMAL CD4+ Ct which makes him eligible to follow the normal vaccination protocol ***SIDE NOTE → Hep A doesn't necessarily have to be given, however it was included in the only correct answer choice MMR, Varicella, & meningococcal - Meningococcal vaccine is usually administered at 2 years

A 12-month-old HIV-positive boy is present for his one-year appointment. He is currently well appearing and his mother has no specific complaints. He has been growing well and is at the 50th percentile for both height and weight. He has previously received three doses of the HBV, DTap, HIB, IPV, and PCV vaccines. His CD4 count last week was >500 cells/uL, and his viral load was undetectable. Which of the following vaccinations are most appropriate at this time? (Hep A, MMR, & Varicella VS MMR, Varicella, & meningococcal)

Start cART & schedule CS at 38 weeks - You want to avoid vaginal delivery to reduce exposure to possible vertical HIV transmission

A 23-year-old primigravid woman comes to the physician at 36 weeks' gestation for her first prenatal visit. She confirmed the pregnancy with a home urine pregnancy kit a few months ago but has not yet followed up with a physician. She takes no medications. Vital signs are within normal limits. Pelvic examination shows a uterus consistent in size with a 36-week gestation. Laboratory studies show: - Hb--------------------------------10.6 - Glucose--------------------------88 - HBsAg----------------------------neg - HCV-Ab---------------------------neg - HIV-Ab----------------------------Pos - HIV load--------------------------(11K) (N <1000) Ultrasonography shows an intrauterine fetus consistent in size with a 36-week gestation. Which of the following is the most appropriate next step in management of this patient? (Start cART & schedule CS at 38 weeks OR Start cART & schedule vaginal delivery at 38 weeks)

Start cART & schedule CS at 38 weeks - Combined antiretroviral therapy (cART) is recommended throughout pregnancy in all pregnant women with HIV infection and should be initiated as soon as possible to reduce the viral load and risk of transmission - CS delivery is recommended in all pts w/ Viral load >1000K Intrapartum zidovudine & CS at 38 weeks - Intrapartum alone is not sufficient to reduce the viral load in this pt

A 23-year-old primigravid woman comes to the physician at 36 weeks' gestation for her first prenatal visit. She confirmed the pregnancy with a home urine pregnancy kit a few months ago but has not yet followed up with a physician. She takes no medications. Vital signs are within normal limits. Pelvic examination shows a uterus consistent in size with a 36-week gestation. Laboratory studies show: - Hb------------------------------10.6 - Glucose------------------------88 - HBsAg--------------------------neg - Hep C Ab----------------------neg - HIV Ab--------------------------Pos - HIV load------------------------11K ---(N <1000) Ultrasonography shows an intrauterine fetus consistent in size with a 36-week gestation. Which of the following is the most appropriate next step in management of this patient? Intrapartum Zidovudine & CS at 38 weeks VS Start cART & schedule CS at 38 weeks)

ELISA for HIV, RPR, serum HBsAg - The pt should be testing for syphilis, HIV, and Hep B Syphilis testing incldues: 1) Screening tests -----VDRL/RPR 2) Diagnostic test -----1) FTA-ABS (after a positive SCREENING test) -----2) Dark-field microscopy

A 25-year-old nulliparous woman at 8 weeks' gestation comes to her physician accompanied by her husband for her first prenatal visit. She has no personal or family history of serious illness. Her vaccinations are up-to-date and she takes no medications. She has no history of recreational drug use and does not drink alcohol. Her vital signs are within normal limits. She is 167 cm (5 ft 6 in) tall and weighs 68 kg (150 lb); BMI is 24.3 kg/m2. She tested negative for HIV, Chlamydia trachomatis, and Neisseria gonorrhoeae 4 years ago. Which of the following tests should be done at this visit? (VDRL, Western Blot for HIV, serum HBsAg OR ELISA for HIV, RPR, serum HBsAg)

PCR for Chlamydia & Gonorrhea - Pt presents w/ secondary syphilis -A) Dx ---1) Confirmation via RPR & fluorescent treponemal antibody test - BOTH ARE POSITIVE - B/c this pt presents w/ an STD → she is at increased risk for other STD's & must be screened HIV-1/HIV-2 immunoassay - This is used as a CONFIRMATORY TEST in HIV - However, this is only used as a FOLLOW-UP to a positive screening test in HIV -A) Screening tests in HIV ---1) Positive Antigen-antibody test -B) Confirmatory tests ---1) HIV-1/HIV-2 immunoassay

A 27-year old woman comes to the physician for a rash that began 5 days ago. The rash involves her abdomen, back, arms, and legs, including her hands and feet. Over the past month, she has also had mild fever, headache, and myalgias. She has no personal history of serious illness. She smokes 1 pack of cigarettes a day and binge drinks on the weekends. She uses occasional cocaine, but denies other illicit drug use. Vital signs are within normal limits. Physical examination shows a widespread, symmetric, reddish-brown papular rash involving the trunk, upper extremities, and palms. There is generalized, nontender lymphadenopathy. Skin examination further shows patchy areas of hair loss on her scalp and multiple flat, broad-based, wart-like papules around her genitalia and anus. Rapid plasma reagin and fluorescent treponemal antibody test are are both positive. In addition to starting treatment, which of the following is the most appropriate next step in management? (HIV-1/HIV-2 immunoassay VS PCR for Chlamydia & Gonorrhea)

Bechet disease -A) Etiology ---1) Usually affects young adults 28-40 ---2) Most common in patients from the Mediterranean region to eastern Asia, including Syria. -B) Signs/Symptoms ---1) Oral ulcers PLUS → MORE SPECIFIC FINDINGS -------a) Recurrent genital ulcers -------b) Recurrent Uveitis -------c) Erythema nodosum/pathergy ---2) Non-Specific symptoms -----a) Fever -----b) Malaise, -----c) Arthralgias HIV - Can also present w/ Ulcers, arthralgias, malaise, & fever - However, key differences are: ---1) HIV symptoms appear in an ACUTE phase → his symptoms would have self-resolved by now ------(pt has had symptoms for the past year)

A 28-year-old man comes to the physician for the evaluation of five episodes of painful oral ulcers over the past year. During this period, he has also had two painful genital ulcers that healed without treatment. He reports frequently having diffuse joint pain, malaise, and low-grade fever. There is no personal or family history of serious illness. He emigrated to the US from Syria with his family four years ago. He is sexually active with one female partner and they do not use condoms. He takes no medications. His temperature is 38°C (100.4°F), pulse is 90/min, and blood pressure is 130/80 mm Hg. Physical examination shows three painful ulcers on the oral buccal mucosa. Pelvic examination shows that the external genitalia has several healing scars. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis? (HIV VS Bechet disease)

Pyrimethamine, sulfadiazine - Pt presents w/ Toxo -A) Signs/symptoms ---1) Seizures ---2) Focal neurological deficits ---3) Confusion, headache, fever -B) Lesion characteristics ---1) MULTIPLE Ring-Enhancing lesions ---2) Lesions in corticomedullary junction & basal ganglia Amphotericin B & flucytosine - Used to treat cryptococcal meningitis - Also presents w/ headache, confusion, ± seizures - However, key differences include ---1) DOES NOT present w/ ring-enhancing lesions

A 28M, presents d/t abnormal mvmts of his arm & face over the last week. The pt has had a 1-to-2-mins episodes of jerking & twitching of the left arm & left side of the face. He has also had daily headaches for a few weeks that are often associated w/ nausea. The pt was recently Dx'd w/ HIV & started anti-retroviral therapy 2-mnths ago. At that time, his CD4+ Ct was 46. He has a Social Hx sig for IV heroin use but recently started a methadone program. Temp is 100F, BP is 124/82, & pulse is 76/min. Cardiopulmonary exam is normal w/no murmur. Left are motor strength is 4/5, & deep tendon reflexes are 3+. An MRI of the brain reveals several ring-enhancing lesions at the gray-white matter junction & basal ganglia. Which of the following is the best TMT for this pt? (Pyrimethamine, sulfadiazine VS Amphotericin B & flucytosine)

Hep A vaccine - Men who have sex with men are at high risk of contracting hepatitis A virus - Since this man did not receive all routine vaccinations as a child, he should be given the hepatitis A virus vaccine now Varicella & MMR - Live vaccines should not be administered to HIV pts w/ CD4+ Ct < 200 ----(Pt has CD4+ Ct of 190) Pneumococcal 23 vaccine - Although this IS Recommended in HIV pts → He should be given the PCV13 vaccine first - B/c this pts vaccine status is unknown, the correct order for pneumococcal vaccines is: ---1) PCV13 ---2) Pneumococcal 23 vaccine

A 29-year-old man comes to the physician in June for a follow-up examination after being diagnosed with HIV infection 3 months ago. He has been taking combined antiretroviral therapy since then. He feels well. He is sexually active with both female and male partners and regularly uses barrier protection. He does not smoke and drinks 2-3 glasses of wine on weekends. The patient did not receive any childhood vaccines besides the hepatitis B virus vaccine. Six years ago, he received the tetanus toxoid, diphtheria toxoid, and acellular pertussis vaccination. His temperature is 37°C (98.6°F), pulse is 75/min, and blood pressure is 125/75 mm Hg. Physical examination shows no abnormalities. His CD4+ T lymphocyte cell count is 190/mm3. Which of the following health maintenance recommendations is most appropriate at this time? (MMR VS Varicella VS Pneumococcal 23 vaccine VS Hep A vaccine)

Bronchoalveolar lavage - The pt presents w/ symptoms concerning for HIV/AIDS infection, including: -A) Signs/symptoms ---1) White plaque ---2) Atypical pneumonia -------a) Diffuse, symmetric infiltrates (On CXR) -------b) Difficulty breathing -------c) Dry cough ---3) Elevated β-D-glucan levels -------(indicates P.jiroveci infection) -B) MGMT ---a) Diagnostic test -----1) Bronchoalveolar lavage (silver staining) --------(in YOUNG PTS) -----2) Sputum sample --------(in older pts) ---b) TMT -------1) TMP-SMX → High dose (double-dose) Urine antigen - This test is a rapid diagnostic test available for identifying infection with Legionella pneumophilia and Streptococcus pneumoniae - Both pathogens cause pneumonia, which may present with dyspnea, dry cough, fine crackles and rhonchi - However, key differences are: ---1) Legionella usually presents w/ diarrhea ---2) Strep causes CAP which presents as a lung CONSOLIDATION -----(pt has DIFFUSE INFILTRATES)

A 3-month-old girl is brought to the emergency department because of a 2-day history of progressive difficulty breathing and a dry cough. Five weeks ago, she was diagnosed with diffuse hemangiomas involving the intrathoracic cavity and started treatment with prednisolone. She appears uncomfortable and in moderate respiratory distress. Her temperature is 38°C (100.4°F), pulse is 150/min, respirations are 50/min, and blood pressure is 88/50 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 87%. Oral examination shows a white plaque covering the tongue that bleeds when scraped. Chest examination shows subcostal and intercostal retractions. Scattered fine crackles and rhonchi are heard throughout both lung fields. Laboratory studies show a leukocyte count of 21,000/mm3 and an increased serum beta-D-glucan concentration. An x-ray of the chest shows symmetrical, diffuse interstitial infiltrates. Which of the following is most likely to confirm the diagnosis? (Bronchoalveolar lavage VS Urine antigen test)

Erythromycin - Pt presents w/ bacillary angiomatosis -A) Signs/Symptoms ---1) Angiomatous skin lesions ---2) Positive Warthin-Starry stain ------(small black bacteria) -B) MGMT ---1) Erythromycin → (DOC) Amphotericin B - Used to treat disseminated/systemic candidiasis

A 30-year-old woman with HIV infection comes to the emergency department because of fever and multiple skin lesions for 1 week. She also has nausea, anorexia, and abdominal pain. The skin lesions are nonpruritic and painless. She has smoked one pack of cigarettes daily for 15 years and drinks 2 beers daily. She has been using intravenous crack cocaine for 6 years. She appears ill. Her temperature is 38°C (100.4°F), pulse is 105/min, blood pressure is 110/75 mm Hg. Her BMI is 19 kg/m2. Examination shows track marks on both cubital fossae. There are white patches on her palate that can be scraped off. There are several red papules on the face and trunk. Her CD4+T-lymphocyte count is 98/mm3 (N ≥ 500). Biopsy of a skin lesion shows vascular proliferation and small black bacteria on Warthin-Starry stain. Which of the following is the most appropriate pharmacotherapy? (Amphotericin B VS Erythromycin)

Influenza & Pneumovax - Pt has a CD4+ of 300 - This means that he can receive: ---1) Influenza ------(if its the right season) ---2) Pneumovax ------(if he has already received the PCV13 vaccine) Influenza & Pneumovax & PCP prophylaxis - Only it pts CD4+ was < 200 -----(pt has CD4+ of 300)

A 32-year-old African-American male presents to the physician's office with complaints of an unusual rash on his tongue. He states that he's had white plaques on his tongue for several weeks that easily rub off when he brushes his teeth and tongue. He became concerned that it might be a serious condition after they failed to resolve on their own. He also complains of extreme fatigue and a persistent runny nose and sore throat for the past month. He denies any known sick contacts. Head and neck examination is significant for white plaques that easily brush off the tongue and soft palette as well as cervical adenopathy. Results of a series of laboratory tests are below. - Leukocytes---------------------2700K - Hb------------------------------11.0 - PLTS-----------------------------230K - HIV antibodies------------------Positive - CD4+ cells-----------------------300 A tuberculin skin test reveals 3 mm of induration. Serology for toxoplasma gondii is negative. In addition to initiating antiretroviral therapy, which of the following interventions is most appropriate for this patient? (Influenza & Pneumovax VS Influenza & Pneumovax & PCP prophylaxis)

MMR vaccine - Although the pt is vaccinated for chicken pox → his vaccination status for MMR is UNKNOWN - Additionally, his CD4+ is 480 (Almost normal) so this vaccine is ok to administer -----(would not be ok in HIV pts w/ CD4+ <200) BCG vaccine -No longer given in the US No vaccine - Pt needs protection from MMR

A 34-year-old man comes to the physician for a routine health maintenance examination. He was diagnosed with HIV 8 years ago. He is currently receiving triple antiretroviral therapy. He is sexually active and uses condoms consistently. He is planning a trip to Thailand with his partner to celebrate his 35th birthday in 6 weeks. His last tetanus and diphtheria booster was given 4 years ago. He received three vaccinations against hepatitis B 5 years ago. He had chickenpox as a child. Other immunization records are unknown. Vital signs are within normal limits. Cardiopulmonary examination shows no abnormalities. Leukocyte count shows 8,700/mm3, and CD4+ T-lymphocyte count is 480 cells/mm3 (Normal ≥ 500); anti-HBs is 150 mIU/mL. Which of the following recommendations is most appropriate at this time? (BCG vaccine VS MMR vaccine VS No vaccine)

Urolithiasis - Pt is taking INDINAVIR - AE of Indinavir includes: ---1) Stone formation in up to 20% of pts Pancreatitis - HIV meds associated w/ pancreatitis are: ---1) Didanosine (NRTI) ---2) Stavudine (NRTI) Hepatic failure - AE of nevirapine (NNRTI).

A 35-year-old man comes to the physician because of a 6-month history of fatigue and increased sweating at night. He says that he feels "constantly tired" and needs more rest than usual although he sleeps well. In the morning, his sheets are often wet and his skin is clammy. He has not had any sore throat, runny nose, or cough recently. He has not traveled anywhere. Over the past 4 months, he has had a 6.8-kg (15-lb) weight loss, despite having a normal appetite. He does not drink or urinate more than usual. He is 181 cm (5 ft 11 in) tall and weighs 72 kg (159 lb); BMI is 22 kg/m2. His temperature is 37.9°C (100.2°F), pulse is 65/min, and blood pressure is 120/70 mm Hg. Physical examination shows no abnormalities. An HIV screening test and confirmatory test are both positive. The CD4 count is 600 cells/μl and the viral load is 104 copies/mL. Treatment with lamivudine, zidovudine, and indinavir is begun. The patient is at greatest risk for which of the following adverse effects? (Hepatic failure VS Pancreatitis VS Urolithiasis)

Pyrimethamine, sulfadiazine, & leucovorin - Pt presents w/ cerebral toxoplasmosis - MRI findings ----MULTIPLE ring enhancing lesions (shows 2) Chemo & radiation - This is the TMT for CNS lymphoma - Presentation is similar to cerebral toxoplasmosis, including: ---headaches, neurological deficits, personality changes ---However, seizures are less common in CNS lymphoma then cerebral toxoplasmosis - CNS lymphoma can be differentiated from Toxo via MRI findings - MRI findings: ----SOLITARY ring-enhancing lesion

A 35-year-old man is brought to the emergency department after experiencing a seizure. According to his girlfriend, he has had fatigue for the last 3 days and became confused this morning, after which he started having uncontrollable convulsions throughout his entire body. He was unconscious throughout the episode, which lasted about 4 minutes. He has not visited a physician for over 10 years. He has smoked one pack of cigarettes daily for 12 years. His girlfriend admits they occasionally use heroin together with their friends. His temperature is 38.8°C (101.8°F), pulse is 93/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. The lungs are clear to auscultation and examination shows normal heart sounds and no carotid or femoral bruits. He appears emaciated and somnolent. There are multiple track marks on both his arms. He is unable to cooperate for a neurological exam. Laboratory studies show a leukocyte count of 3,000/mm3, a hematocrit of 34%, a platelet count of 354,000/mm3, and an erythrocyte sedimentation rate of 27 mm/h. His CD4+ T-lymphocyte count is 84/mm3 (normal ≥ 500). A CT scan of the head is shown. Which of the following is the most appropriate next step considering this patient's CT scan findings? (Chemo & radiation OR Pyrimethamine, sulfadiazine, & leucovorin)

Pyrimethamine, sulfadiazine, & leucovorin - Pt presents w/ Toxoplasmosis -A) Signs/Symptoms ----1) Indicated by multiple ring-enhancing lesions on MRI -B) MGMT ----1) Pyrimethamine, sulfadiazine, & leucovorin Chemo & radiation - Used to treat Primary CNS lymphoma → which also presents w/ ring enhancing lesions - However, Key differences are: ---1) Primary CNS lymphoma typically demonstrates subependymal spread, -------(whereas toxoplasmosis tends to be scattered through the basal ganglia and at the corticomedullary junction ---2) HIV lymphoma also is far more frequently a solitary lesion, -------(whereas toxoplasmosis is usually multifocal (86%) TMP-SMX - Used for PROPHYLAXIS of Toxo (& P.jiroveci) - Can also be used to treat nocardiosis (which also presents w/ ring-enhancing lesions but is VERY rare)

A 35-year-old man is brought to the emergency department after experiencing a seizure. According to his girlfriend, he has had fatigue for the last 3 days and became confused this morning, after which he started having uncontrollable convulsions throughout his entire body. He was unconscious throughout the episode, which lasted about 4 minutes. He has not visited a physician for over 10 years. He has smoked one pack of cigarettes daily for 12 years. His girlfriend admits they occasionally use heroin together with their friends. His temperature is 38.8°C (101.8°F), pulse is 93/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. The lungs are clear to auscultation and examination shows normal heart sounds and no carotid or femoral bruits. He appears emaciated and somnolent. There are multiple track marks on both his arms. He is unable to cooperate for a neurological exam. Laboratory studies show a leukocyte count of 3,000/mm3, a hematocrit of 34%, a platelet count of 354,000/mm3, and an erythrocyte sedimentation rate of 27 mm/h. His CD4+ T-lymphocyte count is 84/mm3 (normal ≥ 500). A CT scan of the head is shown. Which of the following is the most appropriate next step considering this patient's CT scan findings? (Pyrimethamine, sulfadiazine, & leucovorin VS Radiochemotherapy VS TMP-SMX)

Start raltegravir, tenofovir, emtricitabine - Although the patient is not said to have a PMHx significant for HIV, he has RF's associated w/ HIV infection, including: ---1) Sex w/out using condoms → with males & females ---2) Hx of IV drug use - The best next step is to being HIV prophylaxis Administer Hep B IVIG & vaccine - The nurses vaccination status is up to date

A 35-year-old woman comes to employee health services 30 minutes after a work-related incident. She works as a phlebotomist and reports that blood splashed into her right eye when she was drawing blood from a 30-year-old male patient. Immediately following the incident, she flushed her eye with water for several minutes. The patient from whom she drew blood was admitted for hemoptysis, weight loss, and night sweats. He is an intravenous drug user and is sexually active with several male and female partners. The phlebotomist has no history of serious illness and takes no medications. Her immunizations are up-to-date. Physical examination shows no abnormalities. In addition to drawing her blood for viral serologies, which of the following is the most appropriate next step? (Provide reassurance OR Administer Hep B IVIG & vaccine OR Start raltegravir, tenofovir, emtricitabine

IV clindamycin & oral Primaquine - Pt most likely presents w/ P.jiroveci infection (atypical pneumonia) -A) MGMT ---1) IV TMP-SMX for 21 days ------[HOWEVER, THE PT IS ALLERGIC TO SULFA DRUGS] ---2) IV TMP-SMX + Prednisone ------(For pts w/ marked hypoxemia) ----------a) PaO2 <70 mmHg OR ----------b) A-a gradient >30) ---3) IV clindamycin & oral primaquine ------(For pts w/ SULFA allergy)

A 37-year-old woman comes to the physician because of a 2-week history of generalized fatigue and malaise. During this period, she has had a non-productive cough with a low-grade fever. Over the past 6 months, she has had a 13-kg (28.6-lb) weight loss and intermittent episodes of watery diarrhea. She has generalized anxiety disorder and hypothyroidism. She has a severe allergy to sulfa drugs. She is sexually active with 3 male partners and uses condoms inconsistently. She has smoked one pack of cigarettes daily for 20 years and drinks 2-3 beers daily. She does not use illicit drugs. Current medications include paroxetine, levothyroxine, and an etonogestrel implant. She is 162.5 cm (5 ft 4 in) tall and weighs 50.3 kg (110.2 lbs); BMI is 19 kg/m2. She appears pale. Her temperature is 38.7°C (101.6°F), pulse is 110/min, and blood pressure is 100/75 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 94%. Examination of the lungs shows bilateral crackles and rhonchi. She has white plaques on the lateral aspect of the tongue that cannot be scraped off. A chest x-ray shows symmetrical, diffuse interstitial infiltrates. Which of the following is the most appropriate pharmacotherapy? (IV TMP-SMX VS IV clindamycin &oral primaquine)

Topical nystatin - Pt presents w/ Candidiasis -A) MGMT includes: ---1) Topical nystatin ---2) Clotrimazole/ketoconazole Biopsy of lesion - This would be correct if we suspected leukoplakia → which also presents w/ as a white plaque on the oral/buccal mucosa - However, key differences are: ---1) Plaque in Leukoplakia CANNOT BE scraped off ---2) Usually seen in pts w/ a Hx of heavy smoking

A 38-year-old man comes to the physician because of white lesions in his mouth for 4 days. He also has intense pain while chewing food. He was diagnosed with non-Hodgkin lymphoma around 8 months ago. He is undergoing chemotherapy and is currently on his fourth cycle. He was treated for herpes labialis 4 months ago with acyclovir. He has smoked half a pack of cigarettes daily for 15 years. He appears healthy. Vital signs are within normal limits. Cervical and axillary lymphadenopathy is present. Oral examination shows white plaques on his tongue and buccal mucosa that bleed when scraped off. The remainder of the examination shows no abnormalities. Which of the following is the next best step in management? (Topical nystatin VS Biopsy of lesion)

AZ & ethambutol - Pt most likely presents w/ Disseminated MAC infection -A) Signs/symptoms ---1) Constitutional symptoms ---2) Cough ---3) Crackles ---4) Diarrhea ---5) hepatosplenomegaly ---6) lymphadenopathy, ---7) acid-fast organisms -------(Blood culture shows ACID FAST organisms) ---8) ± skin lesions Rifampin & Isoniazid - Used to treat LATENT TB - Generally, a PPD of >5 mm in HIV pts is needed to confirm LATENT TB - However, this pt presents w/ CONSTITUTIONAL SYMPTOMS → which is concerning for ACTIVE TB - If this pt had active TB → he would be given RIPE Erythromycin - Used to treat Bacillary angiomatosis → which also presents w/ violaceous skin lesions - However, those lesions present as ---1) Red, flesh-colored/colorless papules → that bleed easily ------(This pts lesions are most likely from Kaposi Sarcoma)

A 40-year-old man with AIDS comes to the physician because of a 3-week history of intermittent fever, abdominal pain, and diarrhea. He has also had a nonproductive cough and a 3.6-kg (8-lb) weight loss in this period. He was treated for pneumocystis pneumonia 2 years ago. He has had skin lesions on his chest for 6 months. Five weeks ago, he went on a week-long hiking trip in Oregon. Current medications include efavirenz, tenofovir, and emtricitabine. He says he has had trouble adhering to his medication. His temperature is 38.3°C (100.9°F), pulse is 96/min, and blood pressure is 110/70 mm Hg. Examination shows oral thrush on his palate and a white, non-scrapable plaque on the left side of the tongue. There is axillary and inguinal lymphadenopathy. There are multiple violaceous plaques on the chest. Crackles are heard on auscultation of the chest. Abdominal examination shows mild, diffuse tenderness throughout the lower quadrants. The liver is palpated 2 to 3 cm below the right costal margin, and the spleen is palpated 1 to 2 cm below the left costal margin. Laboratory studies show: - Hb-------------------------------12.2 - Leukocytes----------------------4,8K - CD4+ Ct--------------------------44 - PLTS-----------------------------258K - Na+-------------------------------137 - K+---------------------------------4.5 - Cl---------------------------------102 - K+---------------------------------4.9 - ALP-------------------------------202 One set of blood culture grows acid-fast organisms. A PPD skin test shows 4 mm of induration. Which of the following is the most appropriate pharmacotherapy for this patient's condition? (Erythromycin VS Rifampin & Isoniazid VS AZ & ethambutol)

Radiochemotherapy - Pt presents w/ anal cancer → most likely Squamous cell carcinoma -A) Presentation ---1) Hard, exophytic anal mass → that is often tender & bleeds easily -B) MGMT ---1) Radiochemotherapy ---2) Total mesorectal excision -------(only performed if the cancer is located in the rectum → however pts cancer is located in the anal canal)

A 42-year-old man comes to the physician because of several episodes of rectal bleeding over 2 weeks. He has had pain around the anal area for the past month. Six months ago, he was diagnosed with esophageal candidiasis and was treated with oral fluconazole. He is HIV-positive. He has had 9 male sexual partners over his lifetime and uses condoms inconsistently. The patient's current medications include dolutegravir, tenofovir, and emtricitabine. He is 179 cm (5 ft 10 in) and weighs 66 kg (146 lb); BMI is 20.9 kg/m2. Vital signs are within normal limits. Digital rectal examination and anoscopy show a hard 2-cm mass palpable 0.5 cm above the anal verge that bleeds on contact. There is no inguinal lymphadenopathy. The abdomen is soft and nontender. The CD4+ T-lymphocyte count is 95/mm3(N ≥ 500/mm3). A biopsy confirms the diagnosis. This patient is most likely to benefit from which of the following interventions? (Total mesorectal excision VS Radiochemotherapy)

Serology for Toxo - Toxo is an AIDs defining illness -A) Characteristics of Toxo ---1) More common than Primary CNS lymphoma ---2) No Hx of taking anti-retroviral meds ---3) MULTIPLE Ring-Enhancing lesions ---4) Lesions in TOXO more commonly found in the corticomedullary junction & basal ganglia PCR for primary CNS lymphoma - Also presents w/ ring enhancing lesions - However, Key differences are: ---1) Primary CNS lymphoma typically demonstrates subependymal spread, -------(whereas toxoplasmosis tends to be scattered through the basal ganglia and at the corticomedullary junction ---2) HIV lymphoma also is far more frequently a solitary lesion, -------(whereas toxoplasmosis is usually multifocal (86%))

A 43-year-old man presents to the Emergency Department with altered mental status following a witnessed seizure. His wife is present and states that over the past several weeks prior to this event he had been complaining of right-sided weakness and headaches. He had also been acting irritable, which is not typical for him. He was diagnosed with HIV four years ago but was lost to follow-up and has never received antiretroviral therapy. His temperature is 38.3ºC (101.0ºF), pulse is 98/minute, respirations are 12/minute, and blood pressure 135/70 mmHg. He is oriented only to himself, and his speech is slurred. On physical examination, his pupils are 4mm, equal, and reactive. Muscle strength is 5/5 on the left and 3+/5 on the right. Reflexes are symmetric bilaterally. A CT scan reveals a large, discrete lesion with ring-enhancing margins in the left temporal-occipital region measuring 3 cm x 4 cm in diameter and a smaller but similar lesion in the right parietal region. An MRI confirms the presence of these lesions as well as two additional small ring-enhancing lesions in the left frontal and right frontal regions. There is diffuse cerebral edema with evidence of mass effect on the left. Which of the following is the next most appropriate step in the diagnosis of this patient? (Serology for Toxo VS PCR for Primary CNS lymphoma)

HIV-related encephalopathy -A) Signs/Symptoms ---1) Typically affects HIV pts w/ CD4+ Ct <200 ---2) Subacute onset of memory impairment, ---3) Depressive symptoms ---4) MVMT disorders -------(ataxia, dysdiadochokinesia) -B) Associated ---1) Pts also presents w/ concomitant candida infection -------(another AIDS defining condition) Primary CNS lymphoma - Also an AIDS defining illness - However, differences are that primary CNS lymphoma typically presents w/ KEY CHARACTERISTICS including: ---1) Focal neurologic deficits, ---2) Neuropsychiatric symptoms -------(e.g., personality changes), ---3) Headaches & seizures ------[Pt has none of these symptoms]

A 44-year-old man comes to the physician because of progressive memory loss for the past 6 months. He reports that he often misplaces his possessions and has begun writing notes to remind himself of names and important appointments. He generally feels fatigued and unmotivated, and has poor concentration at work. He has also given up playing soccer because he feels slow and unsteady on his feet. He has also had difficulty swallowing food over the last two weeks. His temperature is 37.8°C (100°F), pulse is 82/min, respirations are 16/min, and blood pressure is 144/88 mm Hg. Examination shows confluent white plaques on the posterior oropharynx. Neurologic examination shows mild ataxia and an inability to perform repetitive rotary forearm movements. Mental status examination shows a depressed mood and short-term memory deficits. Serum glucose, vitamin B12 (cyanocobalamin), and thyroid-stimulating hormone concentrations are within the reference range. Upper esophagogastroduodenoscopy shows streaky, white-grayish lesions. Which of the following is the most likely underlying cause of this patient's neurological symptoms? (Primary CNS lymphoma VS HIV-related encephalopathy)

HHV-8 - Pt presents w/ Kaposi sarcoma (AIDs defining illness) - Key to differentiating the lesions in Kaposi Vs Bartonella: ---A) Kaposi -------1) Violaceous plaques, elliptical/round in shape, maculopapular/patch and plaque-like → W/OUT ulceration/necrosis -------2) Always painless & non-pruritic Bartonella - Also presents w/ small, violaceous lesions - However, Key differences are: ---1) Lesions are described as small red/purple papules that gradually expand and coalesce into nodules ---2) Bacillary angiomatosis presents w/ Systemic symptoms -------[Absence of systemic symptoms in this pt makes KS more likely]

A 44-year-old man presents to the emergency department with a "rash" on his left lower extremity, which began three months ago and became purple and raised in the past month. The lesions are not painful or itchy. He denies fevers, chills, and malaise but admits to fatigue. He was diagnosed with human immunodeficiency virus (HIV) four years ago but was lost to follow-up. He was previously sexually active with men only but denies sexual contact since his diagnosis. On physical examination, he is afebrile. His lungs are clear to auscultation. His skin examination is significant for numerous small, violaceous plaques on his left shin and calf area without evidence of necrosis or ulceration. There are no other skin lesions. A CD-4+ count is 240 cells/µL. Which of the following is the most likely etiology for this patient's presenting complaint? (HHV-8 VS Bartonella)

Oral fluconazole - Pt has signs of Oral candida AND CANDIDA ESOPHAGITIS -A) Signs/Symptoms → (Candida esophagitis) ---1) Dysphagia -------a) Food getting stuck -------b) Progressive pain w/ swallowing Nystatin mouthwash - Would only treat the ORAL candida - Pt needs fluconazole to treat esophagitis

A 44-year-old woman comes to the physician because of a 3-week history of progressive pain while swallowing. She has the feeling that food gets stuck in her throat and is harder to swallow than usual. She has a history of high-grade cervical dysplasia which was treated with conization 12 years ago. Four months ago, she was diagnosed with Graves' disease and started on antithyroid therapy. Her last menstrual period was 3 weeks ago. She has had 8 lifetime sexual partners and uses condoms inconsistently. Her father died of stomach cancer. She has never smoked and drinks one glass of wine daily. She uses cocaine occasionally. Her current medications include methimazole and a vitamin supplement. Her temperature is 37°C (98.6°F), pulse is 75/min, respirations are 18/min, and blood pressure is 110/75 mm Hg. Examination of the oral cavity shows several white plaques that can be scraped off easily. The lungs are clear to auscultation. Laboratory studies show: - Hb------------------------------11.9 - Leukocytes---------------------12,2K - PLTS-----------------------------290K - PT time--------------------------12 sec - aPTT-----------------------------38 sec - pH-------------------------------7.33 - Na+------------------------------135 - K+--------------------------------4.9 - Cl--------------------------------104 - BUN-----------------------------13 - Glucose--------------------------110 - Cr---------------------------------1.1 - HIV test--------------------------Pos In addition to starting antiretroviral therapy, which of the following is the most appropriate next step in management? (Nystatin mouthwash VS Oral fluconazole)