HIV - AIDS (main): Difference between revisions
(Text replacement - " pts" to " patients")
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===Asymptomatic===
===Asymptomatic===
*Lasts for ~8yr
*Lasts for ~8yr
*Pts may have conditions that are more common in pts w/ HIV but no indicator conditions
*Pts may have conditions that are more common in patients w/ HIV but no indicator conditions
**Thrush
**Thrush
**Persistent vulvovaginal candidiasis
**Persistent vulvovaginal candidiasis

Revision as of 16:50, 21 June 2016

Background

  • In HIV+ patient presenting to ED, absolute lymphocyte count (ALC) can be used as surrogate for CD4 count [1]
    • A CD4 count of <200 is very likely if the ED ALC is <950 and less likely if the ALC is >1700
    • ALC is useful to confirm, but not exclude a low CD4
  • 14% of people with HIV in US aren't aware of being HIV+[citation needed]

HIV Associated Diseases by CD4 Level

CD4 Count Stage Diseases
>500 Early disease Similar to non-immunocompromised patients (Consider HAART medication side-effects)
200-500 Intermediate disease Kaposi's sarcoma, Candida, bacterial respiratory infections
<200 Late disease PCP, central line infection, MAC, TB, CMV, drug fever, sinusitis, endocarditis, lymphoma, histoplasmosis, cryptococcus, PML
<100 Very late disease Cryptococcus, Cryptosporidium, Toxoplasmosis
<50 Final Stage CMV retinitis, MAC

Clinical Features

Acute Infection

Seroconversion

  • HIV Ab detectable 3-8wk after infection
  • If negative Ab test but high suspicion, can HIV viral load.

Asymptomatic

  • Lasts for ~8yr
  • Pts may have conditions that are more common in patients w/ HIV but no indicator conditions
    • Thrush
    • Persistent vulvovaginal candidiasis
    • Peripheral neuropathy
    • Cervical dysplasia
    • Recurrent Herpes Zoster
    • ITP

AIDS

Differential Diagnosis

HIV associated conditions

Diagnosis

  • Typical lab testing for HIV:
    • Screening test: ELISA
    • Confirmatory test: Western blot
  • Maintain low threshold for additional testing in setting of suspicion of opportunistic infections

Management

HAART

Highly Active Anti-Retroviral Therapy

  • Reduces progression to AIDS and transmission risk
  • CDC Guidelines = all HIV+ individuals should be started on HAART, regardless of CD4 count or viral load[4]
  • Typical first line regimens include a reverse transcriptase inhibitor (NRTI) and an integrase inhibitor
    • tenofovir/emtricitabine (Truvada) PLUS raltegravir (Isentress)
    • tenofovir/emtricitabine (Truvada) PLUS dolutegravir (Tivicay)

Disposition

Suggested Admission

  • New presentation of fever of unknown origin
  • Hypoxemia worse than baseline or PaO2 <60
  • Suspected PCP
  • Suspected TB
  • New CNS symptoms
  • Intractable diarrhea
  • Suicidal
  • Suspected CMV retinitis
  • Ophthalmicus zoster
  • Cachexia or weakness
  • Unable to care for self/receive care
  • Unable to assure F/U

Suggested Discharge

  • Normal or baseline vitals
  • Stable medical condition
  • Able to tolerate PO
  • Adequate follow-up
  • Able to comply with D/C instructions

See Also

References

  1. ↑ Napoli AM, Fischer CM, Pines JM, Soe-lin H, Goyal M, Milzman D. Absolute lymphocyte count in the emergency department predicts a low CD4 count in admitted HIV-positive patients. Acad Emerg Med. 2011 Apr;18(4):385-9. doi:10.1111/j.1553-2712.2011.01031.x. Erratum in: Acad Emerg Med. 2011 May;18(5):565.
  2. ↑ Serrano KD, Westergaard RP. Diagnosis and management of acute HIV in the emergency department. EM Reports, 2012:33;16.
  3. ↑ Gutteridge, David L MD, MPH, Egan, Daniel J. MD. The HIV-Infected Adult Patient in The Emergency Department: The Changing Landscape of the Disease. Emergency Medicine Practice: An Evidence-Based Approach to Emergency Medicine. Vol 18, Num 2. Feb 2016.
  4. ↑ Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. https://aidsinfo.nih.gov/guidelines Accessed 03/04/16
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