inpatient / Infectious disease


Last Updated: 1/21/2203


-- History: *** last CD4 and viral count, regimen, adherence
-- Clinical: *** acute sxs 3-6 weeks after infection: rash, LAD, fever, oral ulcers, pharyngitis; sxs of opportunistic infections - diarrhea, cough, AMS
-- Exam: lymphadenopathy, rashes/skin lesions, oral thrush

-- If initial diagnosis - HIV p24 antigen screen (some modern tests do not need confirmation test) --> HIV-1 and HIV-2 serology immunoassay as confirmation (detectable 3 weeks after infection); PCR of viral RNA load if more acute and suspicion is high; once diagnosed, get viral RNA load and CD4 count
-- Continue home *** Biktarvy, Triumeq, Dovato, etc
-- Ppx: *** bactrim daily BID if CD4 <200, can stop if CD4 >200 for 3 months; itraconazole 200mg daily if in endemic area for histoplasmosis
-- Consult ID if ART to be held, or c/f underlying opportunistic infection
-- Opportunistic Infection Tx: *** HSV - acyclovir; CMV - ganciclovir; Toxo - pyrimethamine → sulfadiazine and leucovorin; PML (JCV) - ART; Cadidiasis - fluconazole; MAC - clarithromycin and ethambutol
-- Consider screening for other STIs based on history (RPR, GC/Ch) and HBV/HCV, TB, toxoplasma

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Clinical Pearls

  • HIV is diagnosed by CD4 <200 or CD4 T-cell <14% of total lymphs or AIDS-defining illness
  • IRIS is worsening symptoms of opportunistic infection1-3 months after ART started (risk if CD4 count is very low at initiation); in general Initiation of ART is safe after opportunistic infection except for CNS TB or crypto
  • You generally don’t need to prophylax against MAC with azithro if ART is initiated immediately when CD4 is found to be <50

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