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Shireesha Virus Jeopordy

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Brandon Fain

on 9 May 2014

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Transcript of Shireesha Virus Jeopordy

500
100
400
200
500
300
200
1
100
Viruses
Antivirals
Head Cases
Vaccines
The Traveler
Viruses 101
TRUE or FALSE
Lipid enveloped viruses are less stable in the environment .
Immune Reconstitution Inflammatory Syndrome
200
What is the first line "one pill-one time a day" option for a patient without contraindications
Atripla
300
400
Name all five classes of ART medications
1. NRTI, 2. NNRTI, 3. Protease Inh, 4. Integrase Inh, 5. Entry Inh, (CCR5 and fusion)
100
How is Hep C most commonly transmitted among the HIV + population
Percutaneously
200
These two genotypes of Hep C have the highest rate of Sustained Virologic Response (SVR) to treatment
Type 2 and 3
300
What two medications are first line for treating HIV/HBV co-infection?
Truvada (emtricitabine / tenofovir) !!!
400
Hep C is traditionally treated with peg-IFN and ribavarin. What class of drug now offers a third agent to this regimen?
Protease Inhibitors
500
This polymorphism offers an increased likelihood of responding to Hep C treatment
IL28cc
100
Differential for ring enhancing lesion in the brain of patient with CD4 <100
Toxo and primary CNS lymphoma
400
At what CD4 count is it appropriate to stop MAC prophylaxis?
500
What diameter of induration is considered a positive PPD in HIV patients?
>5mm
200
How frequently do we screen for cervical cancer in HIV + womem?
Q6mo x2 then Q1yr
300
How frequently do we screen for STDs in high risk MSM?
Every 3 Months
400
What is the recommended management of an HIV patient exposed to active TB
1. Exclude active TB
2. INH x 9mo
500
What is the histologic diagnosis of the most common type of renal disease in HIV patients?
Collapsing FSGS (HIV associated nephropathy)
What medication is first line treatment for the condition pictured below
Fluconazole PO for 2-3wks
Recently started ART with CD4 of 20
Eosinophilic folliculitis
300
What virus is associated with this lesion?
EBV. Hairy Cell Leukoplakia
The first step in treating this disease
Treat the HIV (HAART)
Molluscum Contagiosum
Bactrim, dapsone, atovaquone, aerosolized or intravenous pentamadine
Name four options for prophylaxis against this common AIDS related infection?
What anti-retroviral medication is known for its severe hypersensitivity reaction
1 NNRTI
One Integrase Inihibitor
+
One Protease inhibitor/ritonovir
Truvada (tenofovir / emtricitabine)
1. Ease of administration
2. Minimal Side Effects
3. Efficacy
2 NRTIs
+
(Efavirenz)
Atripla (Efavirenz/tenofovir/
Emtricitabine)
Atazanavir/ritonavir
or
Darunavir/ritonavir
(three pills one time a day)
(one pill one time a day)
Raltegravir
or
Elvitegravir
(tenofovir/emtricitabine/elvitegravir/
cobistat) = Stribild
ART-Naive Patient
+ 50
Abacavir Hypersensitivity
Abacavir (NRTI)
Fever, rash, GI and pulmonary symptoms

Test HLA B5701 prior to starting

First immunogenetic marker used to prevent drug toxicity
Both HIV and HPV are sexually transmitted

Difficulty clearing, leading to persistent HPV infection

Persistent infection of oncogenic HPV subtypes causes more premalignant and malignant cervical disease
Why such frequent Pap smears?
Toxoplasma encephalitis

Primary CNS lymphoma

Progressive multifocal leukoencephalopathy

HIV encephalopathy

CMV encephalitis
Advanced immunosupression without chemoprophylaxis
Radiographic manifestations of PCP
Diffuse ground glass (most common)
Selectively apical
Pneumothorax
Cysts
Nodules
Pleural effusions
Mode of transmission

Immunosuppression -> Impaired clearance

Untreated HIV in HBV/HCV increased rate to fibrosis, cirrhosis, ESLD, HCC and liver related death

Treating HIV but not HBV leads to liver injury
HIV and hepatitis B or C co-infection
CD4 >100 for 3 months
At what CD4 is it appropriate to start ART?
Once the patient is ready
Hepatitis C treatment for HIV positive patients
Factors related to rate of response to treatment:
viral factors (HCV genotype, HCV RNA level)
race/ethnicity (White > AA/latino)
IL28B polymorphism
Degree of liver fibrosis
Co-infection with HIV
prior hepatitis C treatment experience
Muir AJ, Bornstein JD, Killenberg PG; Atlantic Coast Hepatitis Treatment Group. Peginterferon alfa-2b and ribavirin for the treatment of chronic hepatitis C in blacks and non-Hispanic whites. N Engl J Med. 2004;350:2265-71.
PubMed Abstract
4 Conjeevaram HS, Fried MW, Jeffers LJ, et al. Peginterferon and ribavirin treatment in African American and Caucasian American patients with hepatitis C genotype 1. Gastroenterology. 2006;131:470-7.
PubMed Abstract
5 Torriani FJ, Rodriguez-Torres M, Rockstroh JK, et al. Peginterferon Alfa-2a plus ribavirin for chronic hepatitis C virus infection in HIV-infected patients. N Engl J Med. 2004;351:438-50.
PubMed Abstract
6 Carrat F, Bani-Sadr F, Pol S, et al. Pegylated interferon alfa-2b vs standard interferon alfa-2b, plus ribavirin, for chronic hepatitis C in HIV-infected patients: a randomized controlled trial. JAMA. 2004;292:2839-48.
PubMed Abstract
7 Zeuzem S. Heterogeneous virologic response rates to interferon-based therapy in patients with chronic hepatitis C: who responds less well? Ann Intern Med. 2004;140:370-81.
Figure 1. Independent Factors Associated with a Sustained Virologic Response
Odds ratio equal to 1 (dashed line) indicates no difference between the subgroups defined according to the given factor. Bars indicate 95% confidence intervals.

Source: Zeuzem S, Feinman SV, Rasenack J, et al. Peginterferon alfa-2a in patients with chronic hepatitis C. N Engl J Med. 2000;343:1666-72. Reproduced with permission from the Massachusetts Medical Society. Copyright ©2000 Massachusetts Medical Society. All rights reserved.
Evaluation and Treatment of Kaposi Sarcoma
Skin - head and neck, trunk, genitals
Mucus membranes
GI
Pulmonary
H&P
HAART
Decreases number and size of lesion
Multi-factorial
All HAART equal at prevention (HR 0.08)
PIs have anti-angiogenic properties
Studies
Occurs between 3 weeks and 2 months
Often visceral or pulmonary
Pulmonary can be fatal
IRIS
Local
Indications:
Systemic
B Ledergerber, A Telenti, M Egger
Risk of HIV related Kaposi's sarcoma and non-Hodgkin's lymphoma with potent antiretroviral therapy: prospective cohort study. Swiss HIV Cohort Study

BMJ, 319 (1999), pp. 23–24
Intralesional chemo
Radiation
Topical alitretinoin
Widespread skin
Non-responsive to ART
Symptomatic visceral
IRIS
HCV/HIV co-infection
In US 30% of HIV+ are HCV+
Molluscum Contagiosum
Double stranded DNA poxvirus
Mean CD4 100
Painless flesh colored papules anywhere on the body
Treat the HIV then local/topical treatments
Bug most likely responsible for headache, fever, and CSF opening pressure of 200cm H20 in a patient with CD4<50
Cryptococcus
In the ART era
>50% die from conditions other than HIV
Increased malignancies, cardiovascular, liver, and renal disease
TB treatment in HIV
Side Effects
Paradoxical Reactions
Adherence Difficulties
RIPE + HAART
Start RIPE
wait 4-8 weeks
Start HAART
CD4 Count Evidence
< 350 - Grade 1A
350 - 500 - Grade 1B
>500 - Grade 2B
NA - ACCORD - observational
START trial - RCT underway
When to start ART
CD4 > 500
CD4 > 28%
Stage 1
Stage 2
Stage 3
(AIDS)
500 > CD4 > 200
28% > CD4 > 14%
CD4 < 200
CD4 < 14%
AIDS defining lesion
Syphilis IgG + GC and CT NAT
HPV and HSV
Q3mo - three sites
Most common cause of AIDS related cholangiopathy
Cryptosporidium parvum
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