HIV - AIDS (main)

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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
  • Approximately 1.2 million people in the US are living with HIV [2]
    • 13% of people with HIV in US aren't aware [2]
    • Most affected: homosexual & bisexual men, particularly African American [2]

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

View of posterior pharynx showing pseudomembranous oropharyngeal candidiasis in a patient with HIV, with a distribution concerning for esophageal candidiasis (later found on scope).
Kaposi sarcoma. Characteristic purple lesions on the nose in an HIV-positive female.
Kaposi's sarcoma skin lesion
Patch stage Kaposi's sarcoma. Red to brownish irregularly shaped macules and plaques.
An HIV-positive person presenting with a Kaposi's sarcoma lesion with an overlying candidiasis infection in their mouth.
Fundus photograph of CMV retinitis

Acute Infection

Seroconversion

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

Asymptomatic

  • Lasts for ~8yr
  • Patients may have conditions that are more common in patients with HIV but no indicator conditions

AIDS

Differential Diagnosis

HIV associated conditions

Evaluation

CT of Pneumocystis jirovecii pneumonia, showing small nodular lesions surrounded by diffuse GGO.
  • 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
  • CDC (2006) recommends routine HIV screening in health care settings using an opt-out approach [5]
    • Opt-out screening: performing the test after notifying the patient it will be performed & giving them the option to decline

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[6]
  • 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 follow up

Suggested Discharge

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

See Also

External Links

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. ↑ 2.0 2.1 2.2 CDC. Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data. HIV Surveillance Report. 2015; 20(2):1-70.
  3. ↑ Serrano KD, Westergaard RP. Diagnosis and management of acute HIV in the emergency department. EM Reports, 2012:33;16.
  4. ↑ 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.
  5. ↑ Branson B, Handsfield H, Lampe M. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. MMWR. 2006; 55: 1-17.
  6. ↑ 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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