Common Opportunistic Infections in HIV Patients, Part 2

Chris Farnitano, MD

Thursday, October 8, 2009

Noon Conference

Objectives

Discuss most common opportunistic infections (OIs): Dx and Rx

Discuss immune reconstitution disease Review primary OI prophylaxis

Forms

Case Study SP

27 yo male seen in clinic in June 2009 Meds: unboosted atazanavir + Truvada

since 1/09; ranitidine T cells 5; viral load 30,000 Why is his anti-HIV cocktail failing?

Case Study SP

Ritonavir added to boost atazanavir Patient instructed to take ranitidine in

AM only and antivirals in PM Blood Cx for AFB, HIV genotype

ordered

Case Study SP

Admitted to Kaiser August, 2009 with diffuse warm, tender lymphadenopathy

Biopsy performed, read as suspicious for lymphoma

Transferred to CCRMC after 7 days on clarithromycin, ethambutol, rifabutin

T Cells 209, viral load 726 What is patient’s diagnosis?

What are the most common OI’s? Cohort Studies in pre-triple therapy era:

Candida Pneumocystis Carinii Cytomegalovirus Mycobacterium Avium Complex Pneumocystis - second episode Toxoplasmi gondii Herpes zoster

Causes of death, PHC HIV clinic 2007-9

RH: Crypto meningitis TW: street drug overdose SA: sepsis, pneumonia and massive hemoptysis DW: metastatic prostate ca RP: CVA, laryngeal ca VA: PML (progressive multifocal

leukencephalopathy) AM: bacterial pneumonia, ETOH cirrhosis, wasting

OIs diagnosed, PHC HIV clinic

2005-9 PCP pneumonia Esophageal Candidiasis Herpes Simplex Herpes Zoster M. Kansasii immune reconstitution pneumonia Mycobacterium Avium Complex (MAC) Cryptococcal Fungemia, meningitis Histoplasmosis PML

Effect of HAART on Opportunistic Infection Incidence Most OI’s have declined 80-90% OI’s seen now mostly in 3 groups

undiagnosed HIV+ not in care or not adhering to therapy long time “battle-scarred warriors” failing

after a long history of multiple regimens

50-200 T Cells:

Pneumocystis Carinii Pnuemonia Toxoplasmosis Cryptococcus

Toxoplasmosis

<50 T Cells

CMV Retinitis Mycobacterium Avium Complex Cryptosporidiosis Progressive Multifocal

Leukencephalopathy

PML

Ockham's razor does not apply for advanced AIDS

-often multiple diagnoses present simultaneously ie PCP, CMV, KS, Cocci 12% of bacterial pneumonias also have

PCP 10% of PCP pneumonia complicated by

bacterial infection search for second etiology if patient not

improving

Immune reconstitution diseases(HAART attacks)

MAC adenitis CMV TB PCP

Case Study SP

Diagnosis: Immune Reconsitution MAC AFB blood culture from June grew out

MAC on 8/12 (hospital day #13)

Also: Perianal herpes Squamous cell carcinoma-in-situ, buttock Vancomycin-resistant enterococcus, groin

Primary OI prophylaxis

PCP -T cells <200 or thrush Toxo -T cells <100 and +Toxo titer MAC - Tcells <50 TB – INH x 9 months if PPD >5mm or

quantiferon-TB positive

Toxo prophylaxis

Septra SS or DS qd or DS TIW Septra Desensitisation:

1cc qd x 3d, then 2cc qd x 3d, then 5ccqd x 3d, then one SS tab qd

Dapsone 100mg qd +pyramethamine 50mg qweek + leukovorin 25mg qweek

Atovaquone 1500mg qd

MAC prophylaxis

Zithromax 600mg x 2 tabs qweek reduces infection rate 59%

Also seems to reduce risk of PCP

Cytomegalovirus Retinitis - Who Gets It? Rare above 50 T Cells Reactivation disease: most HIV patients

CMV IgG+ (90% of gay HIV+ men) 90% of CMV disease is retinitis

Cytomegalovirus Retinitis - Symptoms painless, progressive visual loss unilateral blurry vision floaters

Cytomegalovirus Retinitis - Signs coalescing white perivascular exudates surrounded by hemorrhage brushfire pattern or tomato and cheese

pizza

Cytomegalovirus Retinitis

Cytomegalovirus Retinitis

Cytomegalovirus Retinitis - Diagnosis if you suspect it, obtain ophthalmologist

confirmation within 24-48 hrs.

Cytomegalovirus Retinitis - Treatment Valgancyclovir 900mg PO BID x 21

days, then qd Adverse effects:

neutropenia ANC<500 in 15% thrombocytopenia anemia 50%: nausea, vomiting, abdominal pain or

diarrhea

Gangcyclivir intraocular implant Consider in addition to systemic

therapy: Surgically implanted depo device Effective for 6 months Replace at 6 months if still not immune

reconstituted Consider for sight threatening lesions near

the central visual field

Mycobacterium avium Complex - Who gets it? T Cells <50 screen with blood culture for AFB x 1 q

3 months to detect subclinical disease

Mycobacterium avium Complex - Symptoms fever, night sweats weight loss diarrhea

Mycobacterium avium Complex - Signs anemia Neutropenia Fever Diarrhea wasting

Mycobacterium avium Complex - Diagnosis Blood culture usually positive if symptomatic

but takes weeks to grow If need to know sooner then do bone marrow

Bx Positive sputum culture usually colonization,

not active disease Positive stool culture may be colonization, not

active disease, mucosal bx more indicative of disease

MAC-filled macrophages in spleen

Mycobacterium avium Complex - Treatment Clarithromycin 500mg BID + Ethambutol 15mg/kg/d +/- Rifabutin 300mg qd Treatment failure rate is high without

immune reconstitution drug toxicity development of resistance

Case Study SP

After 4 months of anti-MAC therapy + potent anti-HIV therapy: T Cells 71 viral load <48 Patient still hospitalized Large effusions persist Dubhoff tube required for feeding Diffuse chest/abdominal adenopathy persists MAC Cx’s show partial/complete resistance to all

MAC drugs except clofazamine Prognosis?

Forms

Summary:

Pyramid approach Prophylaxis simple: Septra and

Zithromax Rule out TB in pneumonia with T Cells

<200 Avoid treating PCP empirically An ounce of prevention pills is worth a

pound of Treatment pills

An ounce of prevention pills is worth a pound of Treatment pills