Snapshot A 44-year-old man presents to his primary care physician for 1 week of worsening malaise, myalgias, sore throat, and chills. He denies any sick contacts or recent travel history. His past medical history is noncontributory. He drinks alcohol occasionally, denies smoking, and is sexually active with 2 men and inconsistently uses condoms. In the past, he has been treated for chlamydia and gonorrhea. He consents for a fourth-generation combination HIV-1/2 immunoassay, which returns positive. An HIV-1/HIV-2 antibody differentiation immunoassay confirms the diagnosis and he is started on tenofovir alafenamide, emtricitabine, and bictegravir. Introduction Definition a blood-borne virus that is transmitted via sexual intercourse sharing needles vertical transmission from the mother to the fetus Epidemiology incidence most commonly transmitted by sexual intercourse or sharing needles Microbiology enveloped virus single-stranded positive-sense RNA retrovirus genes env gene leads to the production of gp160, which is cleaved to produce gp120 and gp41 gp120 attaches to the patient's CD4+ T-cells gp41 leads to fusion and entry into the immune cell gag gene leads to the production of p24 and p17 p24 - viral capsid p17 - viral matrix proteins pol gene leads to the production of reverse transcriptase aspartate protease integrase Pathogenesis HIV attaches to the surface of CD4+ T-cells, along with either CXCR4 or CCR5 coreceptor binding HIV enters the cell, uncoats, and its RNA is reverse transcribed (by reverse transcriptase) into DNA, which integrates into the host's genome, creating billions of viral particles, lysing the host cell, and releasing the viral particles into the bloodstream infecting other CD4+ T-cells Associated conditions opportunistic infections malignancy cognitive decline cardiovascular disease Prognosis high mortality rate (> 90%) in untreated patients Opportunistic Infections Opportunistic Infection Based on CD4+ T-Cell Count CD4+ Count Opportunistic Infection Findings Prophylactic Treatment < 500 mm3 Candida albicans Oral thrush that is scrapable Pseudohyphae on microscopy - Epstein-Barr virus Oral hairy leukoplakia not scrapable HHV-8 Kaposi sarcoma a palpable, nonpruritic lesion that is brown, pink, red, or violaceous in color HPV Squamous cell carcinoma of the anus (in men who have sex with men) cervix < 200 mm3 Histoplasma capsulatum Nonspecific findings such as fevers, night sweats, chills, and weight loss dyspnea nausea and vomiting Macrophages contain oval yeast cells - JC virus reactivation Progressive multifocal leukoencephalopathy demyelinating disease of the central nervous system Pneumocystis jirovecii Pneumonia ground-glass opacity on chest radiography Trimethoprim-sulfamethoxazole if contraindicated, can give dapsone, atovaquone, or pentamidine Cryptosporidium parvum Watery diarrhea Nitazoxanide < 100 mm3 Aspergillus fumigatus Hemoptysis Pleuritic chest pain - Bartonella henselae Bacillary angiomatosis angiomatous skin lesions - Candida albicans Esophagitis white plaques may appear on endoscopy - Cytomegalovirus Retinitis Esophagitis Colitis Pneumonitis Encephalitis Linear ulcers on endoscopy Fundoscopy may demonstrate cotton-wool spots Intranuclear inclusion bodies (owl eyes) - Cryptosporidium spp Watery diarrhea Stool studies will show acid-fast oocysts - Ebstein-Barr virus B-cell lymphoma Central nervous system lymphoma - Mycobacterium avium-intracellulare Non-specific findings fever night sweats weight loss lymphadenitis The goal is to initiate antiretroviral therapy as soon as possible Azithromycin Toxoplasma gondii Ring-enhancing brain abscesses Trimethoprim-sulfamethoxazole if contraindicated, give dapsone, pyrimethamine, and leucovorin in the presence of ring-enhancing lesions, treat with pyrimethamine Presentation Symptoms/physical exam acute retroviral syndrome fever lymphadenopathy sore throat rash myalgia/arthralgia weight loss mucocutaneous ulcers Studies HIV serology fourth-generation combination HIV-1/2 immunoassay best initial test detects both HIV-1 and HIV-2 antibodies HIV p24 antigen screening criteria at least once for all patients age 15 to 65 regardless of risk factors men who have sex with men pregnant women IV drug users patients who engage in unprotected sex those diagnosed with another sexually transmitted disease (STD) interpretation if negative the patient is HIV-negative and no further test is needed if positive perform an HIV-1/HIV-2 antibody differentiation immunoassay confirms the diagnosis determines if the patient is infected with HIV-1, HIV-2, or both viruses if the differentiation immunoassay is negative or indeterminate perform a viral load Viral load (qRT-PCR) used to determine the amount of virus the patient has response to antiretroviral therapy a high viral load is associated with a poor prognosis CD4+ T-cell count and percentage used to determine need for prophylactic medication to prevent the development of opportunistic infections response to antiretroviral therapy HIV genotyping used to determine HIV mutations that can lead to antiretroviral drug resistance Differential Influenza infection and immunosuppression caused by medications differentiating factor negative HIV screening tests few to no risk factors for developing HIV (e.g., having sex without the use of barrier contraception and sharing needles) Treatment HIV-infected breastfeeding mothers preferred to use replacement feedings due to high risk for transmission to the infant HIV-infected patients and vaccinations HIV is an indication for obtaining the following vaccines pneumococcal hepatitis B (if not already immune) meningococcal Medical antiretroviral therapy indication first-line treatment for patients with HIV infection drug regimen 2 nucleoside reverse transcriptase inhibitors (e.g., tenofovir alafenamide and emtricitabine) and an integrase inhibitor (e.g., bictegravir) comments the choice of antiretroviral drugs is guided by drug resistance testing the most common cause of treatment failure is nonadherence post-exposure prophylaxis indication first-line treatment given immediately after HIV exposure (such as in health care personnel) initiate within 72 hours drug regimen tenofovir, emtricitabine, and raltegravir tenofovir, emtricitabine, and dolutegravir pre-exposure prophylaxis indication to prevent HIV infection in high-risk patients drug regimen tenofovir and emtricitabine antiretroviral therapy in pregnancy indication first-line treatment for pregnant women comment women who are pregnant are treated the same as for nonpregnant patients; however, certain medications should be avoided dolutegravir elvitegravir tenofovir alafenamide intrapartum management HIV RNA ≤ 1000 copies/mL mode of delivery cesarean sections are not needed HIV RNA > 1000 copies/mL mode of delivery if < 38 weeks, plan to perform a cesarean section at 38 weeks in order to prevent HIV exposure to the baby via rupture of membranes drug regimen intravenous zidovudine postpartum management indication all infants born to HIV-infected mothers drug regimen mothers with HIV RNA ≤ 1000 copies/mL zidovudine in the infant for 4-6 weeks mothers with HIV RNA > 1000 copies/mL zidovudine, lamivudine, and nevirapine in the infant for 6 weeks Complications Malignancy Cardiovascular and pulmonary disease
QUESTIONS 1 of 15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.ID.17.4867) An 87-year-old man presents to the emergency department with decreased hearing. The patient states that for the past week he has had decreased hearing that is predominantly affecting his left ear. He denies any fever, chills, nausea, vomiting, or changes in his vision. The patient has a past medical history of asthma, HIV, and anxiety. His current medications include HAART, albuterol, and clonazepam. The patient states his last CD4 count taken 2 weeks ago was 650. His temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 100/min, respirations are 11/min, and oxygen saturation is 98% on room air. Laboratory values are obtained and shown below:Hemoglobin: 11 g/dL Hematocrit: 33% Leukocyte count: 2,500/mm^3 with normal differential Platelet count: 197,000/mm^3 Serum: Na+: 139 mEq/L Cl-: 100 mEq/L K+: 4.3 mEq/L HCO3-: 24 mEq/L BUN: 20 mg/dL Glucose: 99 mg/dL Creatinine: 1.1 mg/dL Ca2+: 10.2 mg/dL AST: 12 U/L ALT: 10 U/LOn physical exam, you note an elderly man in no current distress. Cardiopulmonary exam is within normal limits. HEENT exam reveals the finding in Figure A but is otherwise unremarkable. Neurological exam reveals decreased hearing in the patient's left ear but is otherwise non-focal. On otoscopy, the tympanic membrane is hypomobile. Which of the following is the most appropriate next step in management? Review Topic | Tested Concept QID: 109654 FIGURES: A Type & Select Correct Answer 1 CT scan of the head 0% (0/0) 2 Tympanocentesis 0% (0/0) 3 Amoxicillin 0% (0/0) 4 Amoxicillin-clavulanic acid 0% (0/0) 5 Supportive therapy and outpatient referral 0% (0/0) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.ID.17.4732) A 46-year-old Caucasian male with past medical history of HIV (CD4: 77/mm^3), hypertension, hyperlipidemia, and osteoarthritis presents to the emergency department with sudden weakness of his right hand. He reports that the weakness has gradually been getting worse and that this morning he dropped his cup of coffee. He has never had anything like this happen to him before, although he was hospitalized last year for pneumonia. He reports inconsistent adherence to his home medications, which include raltegravir, tenofovir, emtricitabine, TMP-SMX, hydrochlorothiazide, pravastatin, and occasional ibuprofen. His father died of a myocardial infarction at the age of 60, and his mother suffered a stroke at the age of 72. The patient's temperature is 102.6°F (39.2°C), blood pressure is 156/92 mmHg, pulse is 88/min, and respirations are 18/min. On neurological exam, he has 3/5 strength in the distal muscles of the right extremity with preserved sensation. His neurological exam is normal in all other extremities.Which of the following is the best next step in management? Review Topic | Tested Concept QID: 108600 Type & Select Correct Answer 1 Lumbar puncture 5% (3/57) 2 Serology for Toxoplasma-specific IgG antibodies 5% (3/57) 3 Head CT 68% (39/57) 4 Empiric treatment with pyrimethamine-sulfadiazine 21% (12/57) 5 Empiric treatment with itraconazole 0% (0/57) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.ID.17.4694) A 33-year-old man is brought into the emergency department with fever, lethargy, and confusion. He is a cachectic man in acute distress, unable to respond to questions or follow commands. His friend confides that the patient has been sexually active with multiple male partners and was diagnosed with HIV several months ago, but was lost to follow up. Based on prior records, his most recent CD4 count was 65 cells/uL. Which of the following is the most appropriate next step in management? Review Topic | Tested Concept QID: 107880 Type & Select Correct Answer 1 Recheck CD4 and HIV viral load serologies 0% (0/0) 2 Lumbar puncture 0% (0/0) 3 MRI brain with contrast 0% (0/0) 4 CT head without contrast 0% (0/0) 5 Neurological exam with fundoscopy 0% (0/0) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.ID.15.11) A 33-year-old HIV-positive male is seen in clinic for follow-up care. When asked if he has been adhering to his HIV medications, the patient exclaims that he has been depressed, thus causing him to not take his medication for six months. His CD4+ count is now 33 cells/mm3. What medication(s) should he take in addition to his anti-retroviral therapy? Review Topic | Tested Concept QID: 104896 Type & Select Correct Answer 1 Fluconazole 4% (1/24) 2 Dapsone 0% (0/24) 3 Azithromycin and trimethoprim-sulfamethoxazole 71% (17/24) 4 Azithromycin and fluconazole 8% (2/24) 5 Azithromycin, dapsone, and fluconazole 8% (2/24) L 3 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M3.ID.15.9) A 27-year-old G2P1 woman is diagnosed with an HIV infection after undergoing routine prenatal blood work testing. Her estimated gestational age by first-trimester ultrasound is 12 weeks. Her CD4 count is 150 cells/mm^3 and her viral load is 126,000 copies/mL. She denies experiencing any symptoms of HIV infection. Which of the following is appropriate management of this patient's pregnancy? Review Topic | Tested Concept QID: 102539 Type & Select Correct Answer 1 Avoidance of antibiotic prophylaxis 0% (0/13) 2 Breastfeeding 0% (0/13) 3 HAART 0% (0/13) 4 HAART after delivery 100% (13/13) 5 Vaginal delivery 0% (0/13) L 3 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.ID.12.2) A 32-year-old HIV positive female known to be non-adherent to her treatment regimen, presents to the hospital with the complaint of new-onset headaches. Her vital signs are only significant for a low-grade fever. Neurological examination reveals right-sided upper motor neuron signs, as well as a inattention and difficulty with concentration. The patient currently does not have a primary medical provider. A CT of the patients head is shown in the image below. What is the next best step in management for this patient? Review Topic | Tested Concept QID: 104887 FIGURES: A Type & Select Correct Answer 1 Perform a biopsy of the lesion 5% (4/87) 2 Perform an analysis for 14-3-3 protein levels 3% (3/87) 3 Begin treatment with pyrimethamine-sulfadiazine 71% (62/87) 4 Begin treatment with albendazole and corticosteroids 13% (11/87) 5 Begin treatment with acyclovir 7% (6/87) L 3 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3