Koors, massaverlies en

vergrote kliereInterne Geneeskunde

– Aansteeklike siektes

– Pulmonologie

– Sub dissiplines

Kindergeneeskunde

Huisartskunde

Dermatologie

Farmakologie

Obstertrie en Ginekologie

Radiologie

Onkoterapie

Davidson’s

• Bladsye 377 tot 402

– Kliniese Ondersoek – 378

– Epidemiologie en Virologie – 380

– Natuurluke verloop en klassifikasie – 383

– Voorkoming – 384

– Opp Infeksies en Maligniteiete – 384 –

– Hantering – 379 –

– HTLV - 401

Risiko vir Infeksie p 380 Davidson’s

• Bloed oortapping

• Moeder na Kind

• Naalde (dwelms)

• Mukosale membrane

– Genitaal

– Non genitaal

• 90%

• 15 – 40%

• 0,5 – 1,0%

• 0,2% - 0,5%

• < 0,1%

Differensiële diagnose van

Limfadenopatie – T 24.11 Davidson

1. Infektief– Virusse: MIV, EBV,

Rubella

– Bakterie: TB, NTBMB, Kat-krap siekte, Brusellose, Siffilis, Strep, Staf, LGV van chlamydia

– Parasiete:Toksoplasmose, tripanosomiase

– Fungi: Histoplasmose

2. Bindweefsel siektes– RA, SLE

3. Neoplasma– Hematologies:

• Limfoom, ALL, CLL

– Metastases• Long, tiroied, maag,

mamma

4. Infiltrasie– Sarkoiedose, Amiloiedose

5. Middels– Phenytoin, allopurinol,

carbamasepien, hidralasien

Geskiedenis –

Simptome van MIV infeksie

• Primêre MIV infeksie (A)

• 2-4 weke : 70-80% – p383 Davidson’s

– Koors (80%)

– Makulo-papulêre veluitslag (60%)

– Moegheid (80%)

– Faringittes met servikale kliere (50%)

– Mialgie en atralgie (50%)

– Hoofpyn en retro-orbitale pyn (40%)

– Mukosale ulserasie (mond 20%, genitaal 10%)

– Aseptiese meningites, enkefalites, miëlittes, polineurites)

Tabel 14.6

P 384

Davidson’s

ELISA

Antibody

testing

are nearly

• 100 % sensitive

(unless a person is

in the window

period)

and about

• 99 % specific

Window period

Window period

CD4 count

• > 500 /mm3 ( > 29%)

– Mild immune deficiency

– Asymptomatic + unlikely to develop OI

• 200 – 500 / mm3 (14-28%)

– Moderate immune deficiency

– some OI

• < 200 / mm3 (<14%)

– Severe immune deficiency

– Opportunistic infections

Surrogaat

• Lotale limfosiettelling

• < 1,25 x 109/l =

– CD4 < 200

• < 0,75 x 109/l =

– CD4 < 50

> 500

200

100

50

Oral thrush, TB, Shingles

PCP, HSV, Candida esophagitis

Toxoplasmosis, Cryptococcosis

MAC, CMV

Time

CD4

Opp Infections

Tabel 14.7

Davidson’s

Lymphadenopathy

Differential diagnosis

• HIV

• Lymphoma

• Kaposi sarcoma

• TB

– Asymmetrical

– > 2 cm

– Skin involvement

– unexplained fever or

– weight loss

Parotid enlargement and

dry mouth

Pictures taken from booklet: Common oral lesions in Children and Adults

University of Stellenbosch

Oral Hairy Leukoplakia

Etiologie?

Aphthous ulcers

• Extremely painful

– 2% lidocaine gel

– Systemic pain killers

• Topical Hibident mouth rises with Kenalog in orabase 3 x per day

• Systemic prednisone if no response

From Common oral lesions

in Children and Adults

University of Stellenbosch

Treatment of esophageal

candidiasis

•14 day

fluconazole

(200mg/d orally)

Prophylaxis for PCP

Indication BactrimR

• CD4

< 200/mm3

•Stage 3 or 4

infection

Co-trimoxazole

1 DS /day

2 SS /day

When to stop

BACTRIM?

IF CD4 has recovered to

> 200 on ARVs

BACTRIM ALLERGY?

Alternative– Dapsone 100 mg /d

PCP TreatmentBactrimR x 21 d

• PO2 < 70 mmHg

– Prednisone

• 40mg b.d x 5 days

• 40mg/ d x 5days

• 20 mg/d x 11 days

Waarvan sal die pasient kla?

Presenterende Simptoom

• A – Hoes

• B – Koors

• C - Epilepsie

• D - Hoofpyn

D- HEADACHE• Common symptom in HIV

• Serious causes

Common side effect of ARVs

1st 6 weeks

resolve spontaneously

• Breakthrough meningitis complicating

immune recovery

Severe Headache• new onset or different

• unable to sleep

• vomiting

• temp > 38

• neck stiffness

• confusion

• visual changes

• seizure

• weakness on one side

Cryptococcal meningitis

Indian ink

stain

Cryptococcal Meningitis

1.) Acute therapy

– Amphotericin B ivi

+ Fluconazole

– Fluconazole monotherapy

Cryptococcal Meningitis

2.) Maintenance therapy

– Fluconazole

200mg/d po

Raised

Intracranial pressure

• Remove 20 ml - 30 ml of

CSF daily, till normal

Toxoplasmosis p 392 Davidsons

– Pyrimethamine +

• 100 – 200 mg stat

• Then 50 – 100mg /d

– Folinic acid +

• 10 mg/d

– Sulfadiazine

• 4-8 g/d

– or Clindamycin

• 900 – 1200 mg/d ivi q 6 hourly or

• 300 – 450 mg po q 6 hourly

– suppressive therapy

• Pyr + FA + Sd or Cl

Toxoplasmosis prophylaxis

Indication Preferred Alternatives

• positive IgG

serology

and

• CD4

< 100/mm3

• TMP-SMX

1 DS per day

2 SS per day

Dapsone +

pyrimethamine

+ folinic acid

CNS lymphoma

Tabel 14.16

Davidson’s

Severe Eye problems

Same day referral:

– Shingles – face

– One painful red eye

– Sudden change in vision

CMV retinitis

- sudden loss

of vision in

one or both

eyes

• Most days x 1/12 = stage 3 disease

Bactrim prophylaxis

• Wasting disease: weight loss + diarrhoea / fever > 1/12

= AIDS defining illness

- ARVs regardless of CD4

P 33

Diarrhoea

Not on ARVs

usually caused by organisms

which respond poorly to

antibiotics

– best treatment = ARVs

Diarrhoea on ARVs

• d4T and AZT

usually resolves in 1st 6 weeks

• ddI and Kaletra

can cause loose stools

Shingles

SAME DAY REFERAL– Eye / Meningitis /< 72 hours

Acyclovir (ZoviraxR)

800mg, 5 x /d

Systemic analgesics– Paracetamol, Ibuprofen, Codein

– Amitriptyline

HIV+ persons with Chikenpox

are at risk for:

• prolonged new lesion formation and

• extensive cutaneous involvement

• secondary bacterial infection

• life-threatening visceral dissemination

Varicella pneumonia

• varicella in HIV is

more commonly

associated with severe

disease

• varicella pneumonia

has a mortality of up

to 40%

Management of varicella in HIV

• Acyclovir: 800mg orally 5 x per day for 7 days

• HIV or AIDS patients with pneumonia, encephalitis, haemorrhagic manifestations or multi-organ involvement

– IV acyclovir -10mg/kg 3 x per day for 7 days

Herpes Simplex

• Painful – Lignocaine gel + paracetamol

• Gargle with salt water

• Acyclovir

Antiviral Therapy

• Limited salvage regimes

• First regimen = best change of success

• Once failure

– limited fall back options

– evolution of triple-class resistance can occur

rapidly after the second regimen fails

Wie moet HAART kry?

Tabel 14.25 Davidson’s

– CD4: < 200 /mm3

of

– WHO stadium 4 siekte

Failure of therapy – 400plasma HIV RNA levels not > 1 log drop at 6-8 weeks

> 0.6 increase in VL from its lowest levels

• non-adherence

• inadequate potency of drugs

• suboptimal levels of antiretroviral agents

• Drug interactions or toxicity

• Previous ARVT or resistance

• Very high baseline VL

• other factors that are poorly understood