Chapter 37: Immunodeficiency, HIV and AIDS

HSV treatment

Acyclovir, famciclovir, valacyclovir

Window Period

After infection is in, test negative for HIV antibodies (4 weeks- 6 months)

Viral Set point

Balance between amount of HIV in the body and the immune response- Time during which viral burden setpoint is achieved- includes acute symptomatic and early infection phases

HIV asymptomatic: Category A- more than 500 CD4 lymphcytes

By 6 months the viral replication reaches a lower, but steady rate, viral set point, lasts an average of 8-10 years before major complications develop, feels well and has very few symptoms

Nutrition and HIV

Calorie counts, maintain/increase Weight, appetite stimulants, dronabinol, deficient in calories and protein, many are lactose intolerant

Diarrhea and HIV

Can be devastating with AIDS- weight loss, fatigue, fluid and electrolyte imbalances, perianal skin excoriation,weakness, inability to perform ADLs, cells lining the intestines of enteric pathogens

Lymphoma Treatmetn

Chemo and radiation is short lived

Myobacterium Avium complex treatment

Chemoprophylaxis using clarithromycin or azithromycin, secondary prophylaxis- may be discontinued in patients with sustained increase in CD4

Candidiasis

Clotrimazole, antifungal- nystatin suspension, ketocaonazole, fluconazole

HIV symptomatic: Category B 200-499 CD4 Lymphocytes

Conditions caused by complications of HIV, must be either condition due to HIV or defect in cell immunity, or considered to have the clinical course to require management complicated by HIV

HIV enzyme reverse transcripatse

Copies genetic material from RNA to DNA

Vascular Myelopathy

Degeneration of lateral and posterior spinal cord columns, spastic parapresis, ataxia, and incontinence

EIA

Detects antibodies directed specifically against HIV

Kaposi's Sarcoma

Endothelial layer of blood and lymphatic vessels, low CD4 under 50, most common HIV malignancy, ARV increases the incidence, organ transplant, immunosuppression, may affect several body systems, lesions anywhere- brownish pink to deep purple, flat or raised, biopsy to confirm

Diagnosis of HIV

Enzyme Immunoassay (EIA), western blot, Viral load, CD4/CD8 ratio

Hypermetabolic State

Excess calories burned and lean body mass lost, cytokine induced fever accelerates metabolism by 14% for every 1 degree, greater protein metabolism related to fat metabolism, decreased lean body mass

1985

FDA licensed antibody assay using 5-7 m: blood with 2 tests including the EIA and the Western Blot Assay

Immune Reconstitution Inflammatory Syndrome- IRIS

Fever, worsening clinical manifestations and new manifestations

Candidiasis- Thrush

Fungal infection- creamy white patches in oral cavity, difficult/painful swallowing, retrosternal pain, untreated it can involve the stomach and esophagus

CMV retinitis Treatment

Ganciclovir and Foscarnet, priphylactically CD4 under 50, controls but does not kill- may be on it indefinitely

Drug Resistance

Genetic mutation causes resistance, risks include monotherapy, inadequate suppression, nonadherence, initiation therapy late in course

Primary Immunity

Genetic, childhood and infancy, males, recurrent infections as it tends to be x-linked, 50% due to lymphocyte errors

CD4 and CCR5

HIV targets the first and monocytes, dendritic cells and microglia, must use chemokine co-receptor for entry, must have both to infect, 1% of Caucasians lack the second

Secondary Immunity

HIV, immunosuppressive therapy, Chemotherapy, increased susceptibility to infection/cancers, impaired immune response

Antiretroviral Agents

Help HIV patients live longer, rarely suffer from AIDS complications with adherence to therapy

Integumentary Complications of HIV

Herpes zoster or simplex, many types of rashes, seborrheic dermatitis- indurated, diffuse, scaly rash involving the scalp and face

Tuberculosis

IV drug use, latent TB increases the risk, can disseminate to CNS, bone, pericardium, stomach, peritoneum, and scrotum, immune reconstitution syndrome occurs more

Antifungal Pneumocystic Pneumonia Treatment

IV or oral, sometimes given prophylactically, can have fevers, rashes thrombocytopenia, monitor kidneys, gradually increase dose

Trnasferrin

If it is low it indicates anemia, liver disease, malnourishment, poor protein intake

Antidepressants

Imipramine, desipramine, and fluoxetine, psychotherapy and pharmacotherapy, alleviate fatigue and lethargy, Methylphenidate

AIDS: Category C: Less than 200 CD4 lymphocytes

Immune system significantly compromised

Cytomegalovirus Retinitis

Infection in the eye, can cause blindness, asymptomatic of floaters, scotomata (Loss of vision within field) or reduced visual acuity

Finalizing HIV

Integrase splices DNA into cell DNA, which makes new viral proteins and viral RNA, HIV protease cleaves these new protein which joins the RNA into new viral particles, and those bud from the cell and start the process all over

Side Effects of Antiretroviral Therapy

Lipodystrophy syndrome (fat redistribution, more fat in abdomen and breast, increased fat loss in legs, arms and face), hypercholesterolemia, heart disease, diabetes

GI complications

Loss of appetite, N/V, esophageal candidiasis, chronic diarrhea, Wasting syndrome

CDC and HIV 2003

Make testing routine, Implement new models for diagnosis, prevent new infections, further decrease in perinatal transmission

Mantoux Test- PPD and HIV

May not response in late infection as the body does not have enough immune to respond- test all newly infected people

Appetite stimulants

Megestrol acetate- oral progesterone

Risks for HIV/AIDS

Men who have sex with men, young men of color

Pneumocystic Pneumonia

Most common infection usually due to P. jiroveci, nonproductive cough, chills, SOB, dyspnea, chest pain for weeks to months between symptoms and documentation of disease, mild hypoxemia, if untreated there is significant pulmonary impairment, respiratory failure can occur in 2-3 days

Rapid test- 20 minutes

Must have developed the antibodies, most oeople at 1 month will have developed the antibodies, almost all will in 3 months, and some as early as 2-3 weeks

Do not prevent infection

Non latex condoms and Nonoxynol-9

Peripheral neuropathy

Pain and numbness in extremities, weakness, diminished DTR, orthostatic hypotension, and impotence

Primary Infections- Acute HIV

Period from infection until the development of antibodies, intense viral replication and dissemination throughout the body, mono kike symptoms: Fever, enlarged lymph nodes, rash, muscle aches, and headaches (about 3 weeks in, resolves in 1-3 weeks), viral set point

PreP- Truvada

Pre-exposure prophylaxis- drug for people at risk of developing HIV, take at the same time everyday- immunity against HIV, $1000/month

Viral Load Test

Quantifies HIV RNA- track response to HIV treatments- if high there is more lymphocyte destruction, Reverse-transcriptase-(PT-PCR) and Nucleic acid sequence-base damplification (NASBA)

HIV Antibody Tests

REcommended for all 13-64, meaning of test and possible results nust be explained

Antidiarrheal Treatment

Recurr, chronic problem, Octreotide acetate- sandostatin: inhibits GI motility and secretion of water and electrolytes

Treatment goals for HIV

Reduce associated morbidity and prolong duration and quality of survival, restore and preserve immunologic function, maximal and durably suppress HIV plasma load, Prevent HIV transmission

RNA

Retrovirus genetic Material

Post Exposure Prophylaxis of HIV

Same meds used to treatm starts immediately after exposure, no benefit if over 72 hrs, done for 4 weeks

Risky Behaviors

Sharing infected injection drug use equipment, having sex with infected people, infants born to HIV infected moms and/or breastfed by them

Kaposi's Sarcoma Treatment

Surgical excision of lesions, liquid nitro, radiation, alpha-interferon, no specific treatment for survival, not normally life threatening unless it affects pulmonary or GI

Other infections

T gondii, Tuberculosis, syphilis, vascular myelopathy, peripheral neuropathy

HIV Lifecycle

Takes over cells to invade, replicate and spread, targets lymphocytes (WBCs)- specifically T cells (CD4 especially)

Complementary and Alternative Modalities

Treat the whole person, humor, hypnosis, faith healing, guided imagery, nutrition, durg and biological, physical forces and devices, many do not report use to health care providers

Alpha-interferon

Tumor regression and impaired immune system function- IV

Gynecologic Complications of HIV

Vaginal yeast infections, cervical cancer, PID, menstrual abnormalities- amenorrhea or bleeding between periods

HIV encephalopathy

Virus in brain and CSF, difficult to distinguish, depressed, fatigue, memory deficits, headaches, difficulty concentrating, confusion, psychomotor slowing, apathy, followed by cognitive impairments, delay in verbal, vacant stare, spastic paraparesis (Slight weakness/[paralysis of lower extremities), hyperreflexia, psychosis, hallucinations, tremors, incontinence, seizures, mutism, death

Serodiscordant

When one person is infected their partner can be at risk- artificial insemination as pregnancy can be an issue

1996

When we enacted standard precautions

Pentamidine-antiprotozoal for Pneumocystic Pneumonia

alternative Agent, hypotension, altered glucose metabolism, hepatic dysfunction, neutropenia

Viral load testing during treatment

at diagnosis and ever 3-4 months after, should decline and continue to decline below detectable levels by week 16-20

Effective Treatment

at least 3 from 2 different classes, some have combined 2 in 1 to promote adherence- Targets different stages in HIV lifecycle

HIV gp 120 and gp 4

attach to uninfected CD4 lymphocytes at the CD4 receptor and 1 of 2 coreceptors, dusing with the cell membrane

Western Blot Assay

confirm seropositivity when EIA is positive

Adherence of ARV

if nonadherent it raises the risk of drug resistance, individualized plan is best, lifelong therapy, barriers include substance abuse, depression, lack of social support, treatment fatigue

Wasting Syndrome- category C

lose 10% of Body weight: Emaciated, diarrhea, body breaks down muscle, febrile, cakeptic (Wasting), hyper metabolic State, similar to sepsis or trauma, due to anorexia and fever

B cell lymphomas

second most common malignancies, much younger than the general population, develops outside lymph nodes in the brain, bone marrow and GI tract