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