AIDS – Acquired Immune Deficiency Syndrome

• • • A syndrome of opportunistic infections that occur as the final stage of infection by the

human immunodeficiency virus

(HIV) • Destruction & progressive loss of the immune function Can affect any organ First identified in 1981

AIDS Spectrum

• • • Infected individuals that appear healthy • No signs of infection Chronic Illness Terminal Stage Disease

AIDS Spectrum

• • From the time of infection until full blown AIDS can take 1 year to 15 years May take 6 weeks to a year from time of infection to when a person becomes HIV positive • • May pass it on to others False sense of security

Transmission of AIDS

• • • • • Transmitted through body fluids • • • • • Tears Saliva Blood Sexual Intercourse Mother’s Breast Milk Homosexuals, IV drug users/infected needles Sex with multiple partners Blood transfusions Organ transplants

Protection Against AIDS

• UNIVERSAL/STANDARD PRECAUTIONS!!

• Gown, Gloves, Goggles • Protection from needle sticks • Never recap needles

Opportunistic Infections

• • • Skin lesions • Purplish blotches or bumps on the face & extremities Pneumonias • Bacterial (H Influenza & Streptococcus) Viral Infections • • Cytomegalovirus most common virus Effects the lungs and eyes

Opportunistic Infections

• • • • Kaposi’s Sarcoma • Cancer of skin spreading to other sites (lungs & GI) Tuberculosis Fungal Infections • • Mucosal & tongue Candidiasis Fungal Pneumonias (Pneumocystis Carinii) • Eye infections Cervical Cancers

Treatment

• • • • • Supportive Care Oxygen Psychological counseling Anti-viral agents • • • AZT Retrovir Videx Treat individual infections

Treatment

• Pneumocystis Carinii Pneumonia • IV or aerosolized pentamidine • Trade Name: Nebupent • Aerosolized pentamidine associated with less side effects.

• Administered is given with Respirgard II nebulizer • Series of 3 one-way valves • • Expiratory filter to trap exhaled particles Particle size needs to be 1-2 microns to deposit in the alveoli

Dosage of pentamidine

• • Comes in a dry powder 300 mg vial must be reconstituted with 6 mL of sterile water.

• • The entire 6 mL is placed in the nebulizer.

Give a bronchodilator before giving the pentamidine.

• Given on out-patient basis; 300 mg/once a month.

Environmental Exposure to Healthcare Worker

• Risk to Healthcare Workers (HCW) • • Exposure to the drug. Risk of infection with TB often associated with AIDS (airborne transmission).

• HCW should be tested periodically for TB.

• Nursing and Pregnant women should avoid exposure to the drug.

• •

Environmental Risk of HCW

HCW have developed • • Bronchospasm Conjunctivitis Need to protect themselves during administration • • Gloves, mask and goggles Stop nebulization if the patient takes the mouthpiece out of their mouth or if they stop to cough..

• Use an isolation booth or hood assembly with an exhaust fan and high efficiency filter.

Lung Abscess

• • • Lung abscess is a necrotizing infection characterized by localized pus Aspiration of oral and GI fluids containing anaerobic organisms.

• Aspiration a result of impaired cough function (unconscious or obtunded from alcohol) Mouth (between teeth and gums); poor oral hygiene: • Peptostreptococcus sp.

• • • Bacteroides sp.

Fusobacterium sp.

Clostridium sp.

Chest Assessment

• • • • • • • Increased tactile and vocal fremitus Dull percussion note Crackles/rhonchi Pleural friction rub Bronchial breath sounds Whispered Pectoriloquy Bronchophony or Egophony

Clinical Assessment

• • • • • Nonproductive, barking or hacking cough.

• Later, cough becomes productive.

• • Hemoptysis Purulent Painful respirations.

• Pleural is involved.

Fever & sweats Weight loss Periodontal disease

Chest X-ray

• • • • Consolidation with single cavity containing an air-fluid level.

Air bronchograms Pleural effusions Silhouette sign

Aspiration Pneumonitis

• • • • Aspiration of gastric juice with a pH of 2.5 or less causes serious and fatal pneumonia Acute inflammatory reaction does not usually occur until 12-24 hours after aspiration Can lead to the development of ARDS

Mendelson’s Syndrome

Lipoid Pneumonitis

• Aspiration of oil • • Mineral Oils Oils from animal fat

Avian Flu

Influenza Pandemic

• • Pandemic vs. Epidemic Three conditions must be met for an Influenza pandemic to start: • A new influenza virus subtype must emerge for which there is little or no human immunity; • • It must infect humans and causes illness; and It must spread easily and sustainably (continue without interruption) among humans.

Past Influenza Pandemics

• 1933: Influenza virus first isolated • • • 1918-1920: Spanish Flu (H1N1) • Hundreds of millions infected; 50 million deaths (600,000 in US) • Mortality highest in 20- to 40-year age group 1957: Asian Flu (H2N2) • Million deaths worldwide (80,000 in US) 1968: Hong Kong Flu (H2N2) • 700,000 deaths (34,000 in US)

Avian Flu

• • • H5N1 virus Thought to have originated by reassortment between multiple cocirculating avian influenza strains prevalent in Hong Kong in 1997.

• Continued evolution since 1997.

• • • Human transmission appears to be associated with close contact with infected poultry.

• Plucking Playing Cock fights Drinking raw duck blood

Human-to-Human Transmission

• Rare • • • 15 family clusters involving more than two family members documented between 1/04 & 7/05.

200 cases worldwide – none in US.

2006: H5N1 found in Azerbaijan, Cambodia, China, Djibouti, Egypt, Indonesia, Iraq, Thailand, Turkey • http://www.cdc.gov/flu/avian/

Symptoms of Avian Flu

• • • • Non-specific complaints of fever.

Cough Dyspnea Conjunctivitis • CXR: Diffuse infiltrates; rare pleural effusions.

• Lab: Leukopenia

Treatment for Avian Flu

• • Supportive Antiviral drugs • amantadine, rimantadine, oseltamivir, and zanamivir • Vaccine • Flu vaccine not effective

Swine Flu

http://www.cdc.gov/h1n1flu/key_fa cts.htm

Severe Acute Respiratory Syndrome (SARS)

SARS Outbreak

• Emerged from Southern China • • First case reported 11/16/02 1/31/03 patient presented to hospital in Guangdong, China.

• Transmission to 49 HCWs and 19 family members.

• • Spread throughout local municipalities.

Carried to Hong Kong by nephrologist attending a wedding.

• Transmission to 15 hotel guests (including international travelers) • Outbreaks in Vietnam, Canada, Singapore, & Phillipines

Coronovirus

• • Novel human coronovirus (SARS-CoV) Coronaviruses are enveloped RNA viruses.

• Some strains well-recognized as causing the common cold.

• Transmission to human thought to be associated with the handling (and eating) of the palm civet, ferret badgers, and raccoon dogs.

Epidemiology & Clinical Presentation

• • • • Transmission is by inhalation of infected respiratory droplets Incubation period is 2 to 10 days Maximum infectivity does not occur at the time of symptom onset (unlike most viruses) • Occurs in 2 nd week and at the time of rapid clinical deterioration.

Initial symptoms resemble influenza, with fever, cough, chills, rigor, and myalgia.

Diagnostic Testing

• CXR: Usually normal initially • Pulmonary infiltrates as disease progresses • Lab: WBC normal or low

Treatment

• • • • Supportive • • 70-80% have full recovery Others develop ARDS-like picture and 50% die Mechanical Ventilation Anti-Viral Agents • • oseltamivir ribavirin ISOLATION!

• • Protection of healthcare workers.

N-95 masks