AIDS / HIV

 

  • We will focus here on common presentations and complications of pts affected by HIV  since these are the ones that are more frequently seen by the ED staff.  Complications are usually seen with CD4 count of less than 200 cells/µL.

 

Acute HIV:

  • Pt is unaware of HIV status and may present with "acute HIV."  In this entity  there is acute viremia and decrease in CD4 counts.  During this period pt experiences malaise, adenopathy, fevers. This period is followed by a return to baseline.

Ophthalmological  Complications:

  • CMV retinitis presents with photophobia, conjunctivitis, eye pain and change in visual acuity or pt may be completely asymptomatic.  On fundoscopic exam fluffy retinal lesions are present.  Treatment with ganciclovir 5mg/kg x 2 wks.  Alternative treatment with, foscarnet, cidofovir or intraocular ganciclovir.

Pulmonary Complications:

  • PCP, TB (see above), Histoplasma, CMV (appears as interstitial pneumonia), lymphoma and Kaposi's sarcoma are among many pulmonary manifestations in the HIV affected pt.  In ED it is hard to establish dx, and treatment is often empirically based on lab and Xray results.  It is always prudent to maintain respiratory precautions.

GI Complications:

  • Thrush and esophagitis 2ry to Candida can present with dysphagia/odynophagia - treated   with topical swish & swallow Nystatin or Clotrimazole troches if oral thrush, and if  esophagitis PO fluconazole or ketoconazole.  If above treatment fails or pt shows signs of systemic infection, IV Amphotericin B is used.
     
  • CMV esophagitis is treated with Ganciclovir 5mg/kg IV.
     
  • Herpetic esophagitis is treated with PO or IV Acyclovir.
     
  • Hepatomegaly occurs in 50% of AIDS pts and CMV, MAI, lymphoma and TB should be r/o.
     
  • Diarrhea is another common cause of ED visit.  Causes can be multiple such as Candida, CMV, Isospora, Cryptosporidium, Salmonella, venereal causes, Giardia. Treatment is as any other diarrhea presentation i.e. IVF, check labs, stool for cultures, antb as indicated.
     
  • Subphrenic abscess can occasionally present with hiccups, fever, RUQ pain.  Dx made with  CT.

Kidney:

  • HIV nephropathy 2ry to focal glomerulosclerosis.

Neuro / Psychiatry:

  • Depression, delirium, dementia (treated with AZT) and suicidal ideation are some  of HIV related psychiatric disorders.
     
  • Among neurological manifestations pts with HIV can present with new onset dementia, new onset SZ, AMS, HA. Pts are prone to:
     
    • Meningitis (see below): Cryptococcus must be covered along with other  possible etiologies, when treatment instituted.  India ink is requested  on LP.  TB is another possibility.
       
    • Toxoplasmosis. CT or MRI is diagnostic. Treatment c/w Sulfadiazine100 mg/kg/day + Pyrimethamine 25-50 mg/day and  Folinic acid.
       
  • Other entities that manifest with above S+S are brain abscess, encephalitis, neurosyphilis, lymphoma.

Dermatologic Complications:

  • Kaposi's sarcoma. Treatment is RT and Chemotherapy.
     
  • Eosinophilic Follculitis: 3-5mm lesions. Treated with antihistaminic  or steroids or UV.
     
  • HZV:  Treated with Acyclovir po 800mg 5/day x10days if HIV(+) or with IV Acyclovir if   AIDS or disseminated.
     
  • Molluscum Contagiosum: Small papules with central umbilication. Treated with Zidovudine.
     
  • Bacillary Angiomatosis:   Rochalimaea is an organism transmitted from cats.  Presents as small papules resembling angiomas. Treated with Erythromycin 500 mg PO qid.
     
  • Seborrheic dermatitis: treated with local steroids
     
  • Psoriasis

Other skin manifestations that pts with HIV are prone to are: pruritis, fungal infection in digital web, cellulitis, impetigo.

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