Transcript Infectious Diseases Review Session

Infectious Diseases
Review Session
Hail M. Al-Abdely
Consultant Infectious Diseases
KFSH&RC
Clinical, Virological and Immunological Course
of HIV Infection
1000
800
600
400
Symptoms
200
Infection
Virus in Plasma
0
Death
Detectable
Time 0
VIRUS IN PLASMA
Detectable
12 Years
Clinical, Virological and Immunological Course
of HIV Infection
1000
CD4 Cell Count
800
600
400
Symptoms
Virus in Plasma
200
Infection0
Time 0
Death
Detectable
VIRUS IN PLASMA
Detectable
> 500 cells
CD4 COUNTS
< 200 cells
12 Years
Clinical, Virological and Immunological Course
of HIV Infection
1000
CD4 Cell Count
800
600
400
Symptoms
Virus in Plasma
200
Infection0
Death
Detectable
VIRUS IN PLASMA
Detectable
> 500 cells
CD4 COUNTS
< 200 cells
Time 0
12 Years
Seroconversion
Asymptomatic
AIDS
Clinical, Virological and Immunological Course
of HIV Infection
1000
CD4 Cell Count
800
600
RNA in Plasma
400
Symptoms
Virus in Plasma
200
Infection0
Death
Detectable
VIRUS IN PLASMA
Detectable
> 500 cells
CD4 COUNTS
< 200 cells
Time 0
12 Years
Seroconversion
Asymptomatic
AIDS
Development of AIDS is like an
impending train wreck
Viral Load = Speed of the train
CD4 count = Distance from cliff
HIV
infection
J. Coffin, XI International Conf. on AIDS, Vancouver, 1996
Viral Dynamics of HIV-1 Infection
Latently infected
CD4 lymphocytes
Productively infected
CD4 lymphocytes
<1%
T 1/2 ~1.6d
99%
Uninfected CD4
lymphocytes
2.6 days
per
generation
T1/2 ~5.7 hrs
HIV
<1%
Uninfected activated
CD4 lymphocytes
Long-lived cell
populations
Perelson et.al. Science 271:1582 (1996)
CD4 lymphocytes
infected with
defective virus
Viral dynamics




It takes 2.6 days to produce a new
generation of viral particles
Estimated total HIV production is 10.3 x
109 virions per day
99% of the virus pool is produced by
recently infected cells
Retroviral therapy should be able to reduce
viral load within a few days
GOALS OF THERAPY
Clinical goals: Prolongation of life and improved
quality of life
 Virologic goals: Reduction in viral load as much as
possible for as long as possible to: 1) halt disease
progression, and 2) prevent/reduce resistant variants
 Immunologic goals: Achieve immune
reconstitution that is quantitative (CD4 to normal
range) and qualitative (pathogen-specific immune
response)
 Therapeutic goals: Rational sequencing of drugs in
a fashion that achieves virologic goals, but also: 1)
maintains therapeutic options; 2) is relatively free of
side effects; and 3) is realistic in terms of probability
of adherence
 Epidemiologic goals: Reduce HIV transmission

Antiretroviral Drugs Approved by FDA for HIV
Generic Name
Class
FDA Approval Date
Zidovudine, AZT
NRTI
March 87
Didanosine, ddI
NRTI
October 91
Zalcitabine, ddC
NRTI
June 92
Stavudine, d4T
NRTI
June 94
Lamivudine, 3TC
NRTI
November 95
Saquinavir, SQV, hgc
PI
December 95
Ritonavir, RTV
PI
March 96
Indinavir, IDV
PI
March 96
Nevirapine, NVP
NNRTI
June 96
Nelfinavir, NFV
PI
March 97
Delavirdine, DLV
NNRTI
April 97
Combivir (AZT+3TC)
NRTI
September 97
Saquinavir, SQV, sgc
PI
November 97
Efavirenz, EFV
NNRTI
September 98
Abacavir, ABC
NRTI
February 99
Amprenavir (AMP)
PI
April 99
Lopinavir (LPV)
PI
September 00
EC Didanosine(EC DDI)
NRTI
September 00
Trizivir (AZT+3TC+ABC)
NRTI
September 00
Viral Suppression with Monotherapy
versus Multiple Drugs
90
90
100
80
80
80
70
70
60
60
60
40
50
50
20
Monotherapy
Dual therapy
Triple therapy
*Using the age distribution of the projected
year 2000 US population as the standard.
**Preliminary 1998 data
Good News
Highly active antiretroviral therapy has
Changed our view toward HIV from
inevitably fatal to a manageable disease
over several decades
Bad News
1.
2.
3.
4.
5.
Incomplete response
Complexity of treatment
Short and long term side effects
Resistance
Drug-drug interactions
Bad News
Incomplete response
1.
•
•
2.
3.
4.
5.
Complete RNA suppression and sustained CD4
increase happens only in 60-80%.
Effectiveness is even lower in patients with high
replication rates and extensive antiretroviral
experience.
Complexity of treatment
Short and long term side effects
Resistance
Drug-drug interactions
Viral Suppression with Monotherapy
versus Multiple Drugs
90
90
100
80
80
80
70
70
60
60
60
40
Monot herapy
20
Monot herapy
50
50
Monot herapy
Monotherapy
Dual therapy
Triple therapy
Bad News
1. Incomplete response
2. Complexity of treatment
•
•
•
Too many tablets.
Difficult schedule.
Food factor
3. Short and long term side effects
4. Resistance
5. Drug-drug interactions
Bad News
1. Incomplete response
2. Complexity of treatment
3. Short and long term side effects
4. Drug-drug interactions
5. Resistance
Side Effects of NRTIs
Drug
Common Side effects
Zidovudine
(azt, zdv)
Initial nausea, headache, fatigue, anemia, neutropenia,
neuropathy, myopathy.
Lamivudine
(3TC)
GI side effects.
Didanosine
(ddl)
GI side effects. Peripheral neuropathy in 15%,
pancreatitis.
Zalcitabine
(ddC)
Peripheral neuropathy in 17-31% of trial participants;
oral ulcers.
Stavudine
(d4T)
Peripheral neuropathy (1-4% in early studies; 24% in
expanded access patients with CD4+ counts < 50)
Abacavir
(ABC)
About 3%-5% hypersensitivity reaction: malaise, fever,
possible rash, GI. Resolves within 2 days after
discontinuation.
Side Effects of NNRTIs
Drug
Common Side effects
Delavirdine
Transient rash. P450 3A4 inhibitor
Nevirapine
Transient rash, hepatitis. P450 3A4 inducer.
Efavirenz
Initial dizziness, insomnia, transient rash,
P450 3A4 inducer.
Side Effects of PIs
Drug
Common Side effects
Amprenavir
Rash (20%), diarrhea, nausea
Indinavir
Kidney stones in 6 to 8%: good hydration essential.
Occasional nausea and GI upset.
Nelfinavir
Diarrhea common; occasional nausea
Ritonavir
Nausea, diarrhea, numb lips for up to 5 weeks;
occasional hepatitis.
Saquinavir
Nausea, diarrhea.
Metabolic Complications of PIs
Hyperbilirubinemia
 Hyperlipidemia

 Coronary
artery disease
Insulin resistance
 Abnormal fat distribution.
 Lipodystrophy
 Lactic acidosis

Bad News
1. Incomplete response
2. Complexity of treatment
3. Short and long term side effects
4. Drug-drug interactions
5. Resistance
Drugs That Should Not Be Used With Antiretrovirals
Drug Category
Indinavir
Ritonavir*
Saquinavir
Nelfinavir
Amprenavir
Nevirapine
Delavirdine
Efavirenz
Ca++ channel
blocker
(none)
bepridil
(none)
(none)
bepridil
(none)
(none)
(none)
Cardiac
(none)
amioderone
flecainide
propafenone
quinidine
(none)
(none)
(none)
(none)
(none)
(none)
Lipid Lowering
Agents
simvastatin
lovastatin
simvastatin
lovastatin
simvastatin
lovastatin
simvastatin
lovastatin
simvastatin
lovastatin
(none)
simvastatin
lovastatin
(none)
AntiMycobacterial
rifampin
none
rifampin
rifabutin
rifampin
rifampin
(none)
rifampin
rifabutin
(none)
Antihistamine
astemizole
terfenadine
astemizole
terfenadine
astemizole
terfenadine
astemizole
terfenadine
astemizole
terfenadine
(none)
astemizole
terfenadine
astemizole
terfenadine
cisapride
cisapride
cisapride
cisapride
cisapride
(none)
cisapride
H-2 blockers
Proton pump
inhibitors
cisapride
Neuroleptic
(none)
clozapine
pimozide
(none)
(none)
(none)
(none)
(none)
(none)
Psychotropic
midazolam
triazolam
midazolam
triazolam
midazolam
triazolam
midazolam
triazolam
midazolam
triazolam
(none)
midazolam
triazolam
midazolam
triazolam
Gastrointestinal
Drugs
Bad News
1. Incomplete response
2. Complexity of treatment
3. Short and long term side effects
4. Drug-drug interactions
5. Resistance
Resistance
Genotypic Mutations Associated With Resistance to NRTI & NNRTIs
Agent
ZDV
41
67
69*
3TC
69*
ddI
65
ddC
65
d4T
70
Resistance mutations
151
69
50
ABC
151
184
69*
74
151
184
69*
74
151
184
69*
65
210
75
69*
74
Agent
151
115
215
219
333
333
178
151
184
Resistance mutations
DLV
103
EFV
100
103
NV
100
103
181
108
106
108
179
236
181
188
190
181
188
190
225
Resistance
Genotypic Mutations Associated With Resistance to PIs
Agent
APV
10
IDV
10
NFV
10
RTV
10
20
SQV
10
20
LPV
10
20
24
32
30
32
24
30
32
33
36
Resistance mutations
46 47 48 50 54
63
71
36
46
48
63
71
36
46
48
36
46
36
46
46
54
48
47
50
82
84
82
84
71
82
84
82
84
90
82
84
90
54
63
71
54
63
71
73
73
84
90
88
90
Percentage of patients with plasma HIV-RNA
below 200 copies/ml in the VIRADAPT study
%
<200 copies/ml
Randomized Study
35
30
25
Control
Genotypic
20
15
10
5
0
0
3
6
9
Months
(Adapted from Clevenbergh et al. Antiviral Therapy 2000; 5:65–70)
12
Percentage of patients with plasma HIV-RNA
below 200 copies/ml in the VIRADAPT study
%
<200 copies/ml
Open Study
Randomized Study
35
30
25
Control
Genotypic
20
15
10
5
0
0
3
6
9
Months
(Adapted from Clevenbergh et al. Antiviral Therapy 2000; 5:65–70)
12
Barriers to the Development of an
Effective AIDS Vaccine







Sequence variation
Protective immunity in natural infection not
clearly established
Lack of adequate animal model to study
vaccine protection with HIV
Latency and integration of HIV into host
genome
Limited knowledge about mucosal
transmission and immune responses
Financial disincentives
Ethical issues
MCQs
HAART
Opportunistic Infections
A patient with HIV
infection, treated with
HAART, and a CD4 count
of 240/mm3 has the
findings shown in the
photograph on retinal
(funduscopic) exam. The
most appropriate therapy
is:
1.
2.
3.
4.
5.
Pyrimethamine plus
sulfamethoxazole
Intravenous
ganciclovir
Intravenous
cidofovir
Amphotericin B
No treatment
A 30-year-old man with HIV infection with a CD4 count of 680/mm3 is
referred for evaluation of refractory sinusitis. He reports headaches, purulent
nasal drainage and nasal stuffiness for 2 weeks. There has been no
documented fever. Prior treatment consisted of amoxicillin x 5 days, then
TMP-SMX, one DS bid x 3 days; epinephrine nasal spray and ibuprofen has
been given for 2 to 3 weeks. Diagnostic studies included the following:
CT scan--bilateral air fluid levels in maxillary sinuses
Nasal drainage--PMNs and eosinophils
Culture--moderate S. aureus sensitive to methicillin
WBC--7,800 with 62% PMNs, 4% bands, 20% lymphocytes, 9% monocytes,
5% eosinophils.
The treatment that is likely to be most effective is:
1.
2.
3.
4.
5.
Dicloxacillin
Decongestant nasal spray
Cortisone nasal spray
Ipratropium bromide nasal spray
Cough syrup containing dextromethorphan
A pregnant woman has a CD4 count of 550/mm3
and viral load of 860 c/ml with no antiretroviral
therapy. Which of the following has demonstrated
benefit in preventing perinatal transmission in this
setting?
1.
2.
3.
4.
5.
AZT monotherapy
Nevirapine
HAART
C-section
None of the above
The frequency of HIV perinatal
transmission is low when the viral
load is <1,000 c/ml, but a review
of seven prospective studies of
perinatal transmission in the U.S.
and Europe showed that there
was a significant reduction even
further when AZT was given (JID
2001;183:539).
A 30-year-old woman presents
with watery diarrhea with 6-8
stools/day for nearly 2 months.
She is discovered to have HIV
infection with a CD4 count of
22/mm3. A stool AFB smear is
shown. Which of the following
treatments is most likely to
eradicate the pathogen?
1.
2.
3.
4.
5.
Paromomycin
Trimethoprim-sulfamethoxazole
Albendazole
Nitrazoxanide
Highly active antiretroviral therapy
(HAART
A lymph node biopsy from an HIV-positive
patient currently residing in the state prison is
submitted to the laboratory for acid-fast smear
and culture. The acid-fast smear is reported as
positive. Acid-fast organisms are recovered on
solid medium after 3 days of incubation. This
organism is likely to be:
Mycobacterium xenopi
2. Mycobacterium kansasii
3. Mycobacterium fortuitum.
4. Mycobacterium tuberculosis
5. Mycobacterium avium
1.
All of the following are poor prognostic factors
in Cryptococcal meningitis except:
1.
2.
3.
4.
5.
Cerebrospinal fluid (CSF) leukocytosis
Serum of CSF cryptococcal antigen titer >1:32
Elevated CSF opening pressure
Altered mental status
Low CSF glucose
A 32-year-old drug user is seen in an emergency department with abdominal pain
and fever. He has known HIV infection and a recent CD4 count was 10/mm3. He
reports that he has had intermittent diarrhea with 2 to 6 loose stools daily for about
2 weeks, and then noted nausea, vomiting, and right upper quadrant abdominal
pain. Physical exam shows a temperature of 38.5 C and right upper quadrant
tenderness. Medications include AZT, ddI, TMP- SMX, fluconazole, acyclovir, and
megavitamins.
Laboratory tests show the following:
Hematocrit: 29%
WBC: 3200 (72% PMNs, 8% bands, 10% lymphs, 5% monocytes, and 5%
eosinophils)
Platelet count: 88,000/mm3
Bilirubin: 1.4 mg/dL, AST: 121 U/L, ALT: 135 U/L
Alkaline phosphatase: 860 U/L
Chest x-ray: Negative
Abdominal flat plate: Negative
Ultrasound of abdomen: Dilated biliary ducts without stones
Stool ova and parasite exam with AFB stain: Negative
The most likely cause is:
An adverse drug reaction
Cryptosporidia
3. Cyclospora
4. Entamoeba histolytica
5. Mycobacterium avium
1.
2.
The diagnosis of progressive multifocal
leukoencephalopathy is supported by which of
the following findings?
1.
2.
3.
4.
5.
Cerebrospinal fluid pleocytosis
Cerebrospinal fluid elevated protein
Fever
Rapid onset of symptoms
Brain biopsy with positive stain for SV-40 virus
Which of the following drugs is least likely to
cause lactic acidosis?
1.
2.
3.
4.
5.
AZT
3TC
ddC
ddI
Tenofovir
A 30-year-old man has been treated with AZT, 3TC,
ritonavir, and indinavir for three years. His CD4
count increased from 230 to 550/mm3 with VL<50
c/ml for over two years. He decides to stop therapy.
When should HIV become detectable?
1.
2.
3.
4.
5.
One week
Two weeks
Four weeks
Eight weeks
Three months
Which of the following decreases blood levels of
indinavir?
1.
2.
3.
4.
5.
Delavirdine
Efavirenz
Nelfinavir
d4T
Ketoconazole
Efavirenz decreases the AUC of
indinavir by 31%. The practical
application is that the dose of
indinavir when these two drugs are
used together should be increased
to 1,000 mg q8h. All of the other
drugs that are listed increase the
levels of indinavir.
Which of the following drugs is most likely to
increase the fasting blood glucose?
1.
2.
3.
4.
5.
Tenofovir
Hydroxyurea
Nevirapine
Indinavir
IL-2
There is some substantial
confusion about the agents and
mechanisms of lipodystrophy, but
this is not the case with insulin
resistance resulting in elevated
blood sugar. All protease
inhibitors are associated with
insulin resistance, which can be
measured within days of
administration. Thus, indinavir is
the best option since this is the
only PI on the list.
Food should be given with:
1.
2.
3.
4.
5.
Amprenavir
Indinavir
AZT
Nevirapine
Lopinavir
A 37-year-old man with AIDS is receiving AZT, ddI
and nelfinavir. He has done well with a viral burden
that decreased from 88,000 copies/dL to
undetectable. At his last clinic visit he is noted to
have a CBC showing an absolute neutrophil count of
400/mm3; neutropenia is confirmed. A review of
prior CBCs shows all had ANC values >1800/mm3.
The preferred regimen for this patient among the
options given is:
1.
2.
3.
4.
5.
ddI, d4T, and saquinavir (Fortovase)
d4T, ddI and nelfinavir
3TC, ddI and indinavir
ddC, ddI and ritonavir
ddI, ritonavir and saquinavir
A 40-year-old man with HIV infection and a CD4
count of 360/mm3 is taking INH due to a positive
PPD skin test. After one month of treatment the ALT
increased from 30 IU/dL at baseline to 90 IU/dL.
The upper limit of normal is 35 IU/dL. The patient
is asymptomatic. What treatment should be given?
1.
2.
3.
4.
5.
The current recommendations
Continue INH in same dose
with INH and hepatic function
Discontinue prophylaxis
testing is that increases of 3 - 5Substitute rifampin
fold for transaminase levels
Substitute rifampin + ethambutol should lead to careful
monitoring, but discontinuation
Biopsy the liver and then continue INH
if there is no
of INH is not necessary unless
evidence of drug-induced hepatitis the increase is 5 - 10-fold
higher of the upper limits of
normal.
For the average patient, which of the following
treatments gives the longest delay in relapse of
CMV retinitis?
The median times to progression with initial
with CMV retinitis are:
1.
2.
3.
4.
5.
IV ganciclovir
IV foscarnet
IV cidofovir
Ganciclovir implant
Oral ganciclovir
ganciclovir IV of 47 - 104 days,
foscarnet IV 53 - 93 days,
ganciclovir plus foscarnet IV 129 days,
oral ganciclovir 29 - 53 days,
cidofovir IV 64 - 120 days,
ganciclovir implant (Vitrasert) 216 - 226 days.
Most patients in late-stage HIV infection develop
toxoplasmosis from which of the following?
1.
2.
3.
4.
5.
New infection following exposure to cat stool
New infection following exposure to undercooked meat
New infection from exposure to a patient with
toxoplasmosis
New infection from contaminated water
Activation of latent infection
The risk of which of the following HIV-associated
complications is the least reduced by immune
reconstitution with HAART?
1.
2.
3.
4.
5.
Kaposis sarcoma
HIV-associated dementia
Non-Hodgkins lymphoma
Thrush
Pneumococal pneumonia
A patient sees you complaining of a
sore mouth for 2 days. There is a
history of genital herpes,
pneumococcal pneumonia,zoster,
oral hairy leukoplakia and a positive
PPD. The CD4 count is 205/mm3
and current medications include
nevirapine, nelfinavir, ddI,
hydroxyurea, trimethoprimsulfamethoxazole, and sertraline
(Zoloft). Oral exam is shown in the
figure. A Tzanck prep of the lesion
is negative. Which of the following
is most likely to provide relief?
1.
2.
3.
4.
5.
Acyclovir therapy
Thalidomide therapy
Discontinue nevirapine
Discontinue trimethoprim
sulfamethoxazole
Discontinue nelfinavir
Human herpes virus 8 has been most
convincingly implicated in which of the
following:
1.
2.
3.
4.
5.
Hepatocellular carcinoma
CNS lymphoma
Castleman's disease
Acute myelocytic leukemia
Hypernephroma
Which of the following drugs shows the best
penetration across the blood-brain barrier?
1.
2.
3.
4.
5.
Zidovudine (AZT).
Stavudine (d4T)
Lamivudine (3TC)
Didanosine (ddI)
Zalcitabine (ddC)
With the exception of
abacavir, AZT shows the
best penetration of the
NRTIs across the bloodbrain barrier with CSF
levels that are
approximately 60% of
serum levels (Lancet
1998; 351: 1547).
A 25-year-old HIV-infected man presents to your office with
severe herpes proctitis. The patient has been treated with
acyclovir, 200 mg five times daily for six weeks without
improvement in the lesions. On repeat culture of the rectum,
herpes simplex virus 2 is again isolated and further testing
reveals that this is a thymidine kinase-deficient strain. Which
is the preferred treatment option for this condition?
1.
2.
3.
4.
5.
Foscarnet
Vidarabine
Ganciclovir
Valacyclovir
Famciclovir
A 43-year-old man with AIDS presents with a four-week
history of ataxia, progressive right hand weakness, and tremor.
Physical examination confirms his symptoms. His CD4 cell
count is 56/mm3, and serum antitoxoplasma IgG antibody titer
was negative one year ago. An MRI of the head reveals a
solitary 2 x 4 cm lesion in the left cerebellar hemisphere
which gives a high signal intensity on T2-weighted images but
does not enhance with gadolinium. No mass effect is
demonstrated. The most likely diagnosis is:
1.
2.
3.
4.
5.
Toxoplasmosis
A fungal abscess
Primary CNS lymphoma
Progressive multifocal leukoencephalopathy (PML)
A mycobacterial abscess
Which of the following best predicts long-term HIV
suppression?
1. The nadir of plasma HIV RNA levels following treatment
2. Treatment in relatively early stage disease as indicated by a
CD4 count >200/mm3
3. A relatively low plasma HIV RNA level at the time
antiretroviral therapy is initiated
4. Absence of an AIDS-defining opportunistic infection
5. Use of a regimen that contains 2 protease inhibitors
Which of the following is least likely to cause peripheral
neuropathy?
1.
2.
3.
4.
5.
Lamivudine (3TC)
Stavudine (d4T)
Didanosine (ddI)
Zalcitabine (ddC)
Zidovdine (AZT)
Which of the following may cause a deceptively high CD4
cell count?
1.
2.
3.
4.
5.
HTLV II co-infection
Splenectomy
Major surgery
Pregnancy
Acute administration of corticosteroids
Which of the following vaccines is contraindicated in
patients with HIV infection due to the potential to cause
infection?
1.
2.
3.
4.
5.
Tetanus
Influenza
Varicella
Haemophilus influenzae type B
Hepatitis A virus
Which of the following microbes is most likely to cause a
cerebrospinal fluid showing elevated protein and a
polymorphonuclear pleocytosis in late-stage HIV infection?
1.
2.
3.
4.
5.
Toxoplasma gondii
Cytomegalovirus
Treponema pallidum
JC virus (Progressive multifocal leukoencephalopathy)
Herpes simplex
The most common cause of fever of unknown origin with no
focal symptoms in a previously untreated patient with a
CD4 count of 10/mm3 is:
1.
2.
3.
4.
5.
Disseminated M. avium infection
Disseminated cytomegalovirus
Pneumocystis carinii pneumonia
Toxoplasmosis
Lymphoma
A 45-year-old woman donated blood prior to elective surgery for
urinary incontinence. The blood bank reports that the unit is
repeatedly reactive in a HIV-1 enzyme immunoassay (EIA),
with a negative HIV-1 Western blot. A test done 1 year
previously showed the same results. She has no history of blood
transfusion or injection drug use, and has been sexually
monogamous for ten years with a single partner who has no
known HIV risk factors. Your advice is:
1.
2.
3.
4.
5.
Defer surgery until repeat HIV testing can be done at three months
Advise the patient that she has early HIV infection
Perform testing on her sexual partner to determine if he is the source of the
infection
Test the patient's sexual partner for HIV
Inform the patient that HIV infection is unlikely given the absence of risk
factors and the negative Western blot result
For which of the following exposures would the use of HIV PEP
be recommended?
1. A housekeeper sustains a percutaneous injury while emptying a needle box
on a pediatric ward with no known cases of HIV infection.
2. A nurse has a urine splash to the eye while emptying an AIDS patient’s
urinal.
3. A resident, after assisting with an emergency insertion of a central venous
line into an HIV-infected patient, notices a small tear in his/her glove but
does not observe any blood on his/her skin.
4. A phlebotomist sustains a percutaneous injury while performing phlebotomy
on an HIV-infected patient with low viral load.
5. All of the above.
All of the following are correct about hairy leukoplakia except:
1.
2.
3.
4.
5.
It will respond to treatment with acyclovir
It will respond to treatment with ganciclovir
It is a rare complication of diseases other than HIV infection
It is usually not treated
Scrapings of it will show pseudomycelia
A 27-year-old intravenous drug abuser is referred to you with positive
HIV serology. He is asymptomatic but continues to practice high risk
behavior. Past medical history indicates herpes zoster involving the
right leg one year ago. Initial evaluation shows the following:
WBC 3,400 with 72% PMNs, 5% bands, 15% lymphocytes, 3%
monocytes;
CD4 count 240/mm3;
Chemistry panel normal;
Hepatitis serology HBsAg neg and anti-HBs positive;
VDRL negative;
Chest x-ray negative;
PPD negative. Treatment at this time should include which of the
following?
1.
2.
3.
4.
5.
Pneumovax
Azithromycin prophylaxis
PCP prophylaxis
Hepatitis B vaccine
Acyclovir
Which of the following is correct about Stavudine (d4T)?
1. The major side effect is peripheral neuropathy.
2. High level resistance occurs early in treatment when it is
given as monotherapy.
3. It penetrates the blood-brain barrier better than AZT
4. Tablets should be chewed or dissolved in fluids before
swallowing
5. It commonly causes lactic acidosis
Which of the following conditions in a person with HIV
infection is suggestive of the greatest degree of
immunosuppression?
1.
2.
3.
4.
5.
Peripheral generalized lymphadenopathy
Thrush
Pneumonia due to S. pneumoniae
Cavitary pulmonary tuberculosis
Vaginal candidiasis
A HIV-infected patient has cough, fever, and sputum
production for 4 days. A chest x-ray shows a left lower
lobe infiltrate, the WBC is 4,200/mm3 and a CD4 count is
150/mm3. He takes no medication. The most likely
microbial pathogen is:
1.
2.
3.
4.
5.
S. pneumoniae
Mycobacterium tuberculosis
Rhodococcus equii
P. carinii
Cryptococcosis
A HIV-infected woman has headache, fever, and a seizure.
The CD4 count is 56/mm3, WBC is 3,200/mm3, and a MRI
shows two ring-enhancing lesions. She takes no medicines
other than methadone. The most likely diagnosis is:
1.
2.
3.
4.
5.
Lymphoma
Toxoplasmosis
Cryptococcosis
PML
Herpes simplex encephalitis
Which of the following drugs has been associated with
serious hypersensitivity reactions characterized by
fever, GI distress, and rash?
1.
2.
3.
4.
5.
Efavirenz
Hydroxyurea
Abacavir
Saquinavir
Nelfinavir
The opportunistic organism most likely to infect the adrenal
gland in patients with advanced HIV infection is:
1.
2.
3.
4.
5.
M. avium
Histoplasma capsulatum
Candida albicans
CMV
Cryptococcus neoformans
Which of the following is most likely to show no white blood
cells in cerebrospinal fluid?
1.
2.
3.
4.
5.
Toxoplasma encephalitis
CNS lymphoma
Progressive multifocal leukoencephalopathy
Neurosyphilis
CMV encephalitis
A patient with HIV infection is receiving no medications and
is seen for routine follow-up. At the previous visit 6
months ago, the CD4 count was 860/mm3 and the CD4
percentage was 46%. The viral burden at that time was
562 copies/ml. At this visit the CD4 count is 620/mm3 and
the CD4 percentage is 40%. The viral burden is
undetectable (less than 400 copies/ml). Which of the
following would be most appropriate?
a.
b.
c.
d.
Repeat the CD4-cell count in the same lab
Repeat the CD4-cell count, but use a different lab
Request a complete T-subset analysis
Obtain additional studies for HIV staging including B2
microglobulin and neopterin
e. Do nothing and see the patient in 3 months
A 25-year-old man with advanced HIV infection is hospitalized with fever and
diarrhea of 2-3 weeks duration. He has been treated with ddI, ritonavir,
saquinavir, and trimethoprim-sulfamethoxazole. Exam shows thrush,
wasting, and KS lesions on the face and arms. Admission laboratory studies
show:
Hematocrit of 28%, WBC 3,100/mm3;
CD4 count of 2/mm3;
ALT of 56 IU/L, alkaline phosphatase of 211 IU/L, amylase of 53 IU/L, a
potassium of 3.1 MEQ/L, and an albumin of 2.3 gm/dL;
Chest x-ray is negative;
Blood culture at 48 hours yields S. epidermidis;
Stool C. difficile toxin assay is negative, stool culture is negative,
Stool O&P exam shows Blastocystis hominis.
Treatment directed against which organism is most likely to produce
defervescence?
a.
b.
c.
d.
e.
S. epidermidis
Microsporidia
Blastocystis hominis
Cryptosporidia
M. avium complex
A 27-year-old gay man has negative HIV serology but
continues to practice high risk behavior. He requests
assurance that he does not have HIV infection. The most
sensitive blood test to provide this assurance is:
a.
b.
c.
d.
e.
p24 antigen
Routine serologic test
HIV DNA assay
HIV RNA level
HIV culture
The most common side-effect of nelfinavir is:
a.
b.
c.
d.
e.
Epigastric pain
Diarrhea
Headache
Nephrolithiasis
Neuropathy
Albendazole is effective therapy for most patients infected
by:
a. Toxoplasma gondii
b. Enterocytozoon bienusi
c. Septata intestinalis
d. Cryptosporidia
e. Cyclospora
The average efficiency of HIV transmission with a single
episode of unprotected receptive vaginal intercourse with
an untreated HIV infected source is approximately?
a.
b.
c.
d.
e.
30%
3%
0.3%
0.03%
0.003%
A 30-year old woman with HIV infection and a CD4 count
of 180/mm3 has a platelet count of 40,000/mm3. She
reports mild gum bleeding while brushing teeth, but
denies other forms of bleeding and has not noted
bruising. Her platelet count 3 months ago was
65,000/mm3. Medications do not appear to be the cause
of her thrombocytopenia. What treatment is
appropriate at this time?
a.
b.
c.
d.
e.
IVIG
Prednisone
Splenic irradiation
Danazol
No treatment
A 28-year old gay man has progressive dyspnea and
hypoxemia over 2-3 months. He is afebrile and has a CD4
count of 26/mm3. Chest x-ray shows alveolar infiltrates
bilaterally, hilar adenopathy and a pleural effusion.
Bronchscopy with BAL and a transbronchial biopsy is
negative. A gallium scan negative. The most likely cause
is:
1. Histoplasmosis
2. Coccidiodomycosis
3. Lymphocytic interstitial pneumonia
4. Lymphoma
5. Kaposi sarcoma
Which of the following drugs is recommended for AIDS
patients with bacillary angiomatosis?
1.
2.
3.
4.
5.
Penicillin
Ciprofloxacin
Erythromycin
Cephalosporin
Vancomycin
Which of the following drugs is the most potent inhibitor of
the hepatic p450 metabolic pathway?
a.
b.
c.
d.
e.
Ritonavir
Saquinavir
Rifampin
Nevirapine
Abacavir
A 40-year-old man with HIV infection complains of
headache, fever, and blurred vision. He takes AZT,
3TC, nelfinavir, dapsone, and INH. Exam shows thrush
and perirectal vesicles. A CD4 count is 86/mm3 and a
head MRI is negative. The most likely diagnosis of his
CNS infection is:
a.
b.
c.
d.
e.
T. pallidum
Toxoplasma gondii
Cryptococcus
Progressive multifocal leukoencephalopathy
H. simplex
A 32-year-old woman with HIV infection complains of
intermittent diarrhea without fever for 30 days and
fatigue. She takes d4T, 3TC, nevirapine, dapsone, and
fluconazole. A CD4 count is 70/mm3. The single most
likely diagnosis is infection due to:
a.
b.
c.
d.
e.
Giardia
E. histolytica
C. difficile
Salmonella
Cryptosporidia