Opportunistic Infections in HIV/AIDS
Any CD4 count:
 ...
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Description

Opportunistic Infections in HIV/AIDS

Any CD4 count:

 • Influenza, HAV, HBV, HPV, VZV, S.pneumo, TB

 • PPx: Vax: Flu; HAV, HBV, HPV, PCV 13, PPSV23 after 8 wks; no live vax w/ CD4<200; latent TB: INH/B6 x 9mo

CD4 < 200:

 • Pneumocystis jirovecii (or hx of thrush)

 • PPx: TMP-SMX DS QD (preferred) or 1 SS QD or dapsone 100mg QD or atovaquone 1500mg QD

CD4 < 150:

 • Histo (only if endemic; not in MA) 

 • PPx: Itraconazole 200 mg PO QD

CD4 < 100:

 • Toxoplasma 

 • PPx: TMP-SMX DS QD or dapsone 50mg QD + pyrimethamine 50mg qWk + leucovorin 25 qWk

CD4 < 50:

 • Mycobact. avium complex (MAC) 

 • PPx: Ppx no longer reccommended if ARVs started

MAC:

 • Cx (blood/sputum/bronch/marrow/tissue), AFB stain 

 • Azithro 600mg qday or clarithro 500mg BID + ethambutol 15mg/kg QD

Pneumocystis jirovecii:

 • Typically induced sputum (sens 50-90%) or BAL wash (sens >90%) for dx; Cx not reliable

 • TMP-SMX (15-20 mg/kg/day of TMP IV) x 21d, ± steroids if PaO2 < 70 or A-a >35

Toxoplasma gondii:

 • CT/MRI: ring-enhancing, most pts have IgG+ but not IgM+, brain Bx if Rx fails (r/o CNS lymphoma)

 • Pyrimeth 200mg x1; then by weight + sulfadiazine + leucovorin x6wks

Herpes Simplex Virus (HSV):

 • Oral/genital: DFA, PCR, viral cx CNS: LP + CSF PCR

 • Acycl. 400 PO q8h or valacycl. 1g PO q12h x5-10d; CNS: acycl. 10mg/kg IV q8h x3wk

Cytomegalovirus (CMV):

 • Retinitis: exam; Colitis/esophagitis: bx; PNA: bronch; Neuro: LP with PCR, brain Bx, Blood: PCR

 • In general: ganciclovir or foscarnet IV, switch to PO w/improvement

PML:

 • MRI: non-enhancing lesions, LP with JCV PCR 

 • Only disease-modifying tx is ARVs

Cryptococcus (rare in US pts):

 • Serum and CSF CrAg, serum and/or CSF culture, ↑ CSF opening pressure

 • Ambisome + flucytosine x 2 wkthen high-dose fluc x 8 wkthen low-dose x 1yr

Mucocutaneous candidiasis (esophageal/oral):

 • Clincal dx. White plaque removed w/tongue depressor, +KOH; EGD + Bx

 • Oral: fluc 100mg PO x7-14d vs nystatin S&S; Eso: fluc 100-400mg PO/IV x14-21d)



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Account created for the MGH Internal Medicine Housestaff Manual "White Book" - https://stk10.github.io/MGH-Docs/WhiteBook-2019-2020.pdf
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