Opportunistic Infections

of care is two nucleosides and an integrase inhibitor. Test the HLA type of the patient before starting abacavir.

PrEP or preexposure prophylaxis is given to high-risk patients who have known HIV-positive sexual encounters or who share needles. They take tenofovir and emtricitabine prior to exposure, continued for 30 days after last exposure. Tenofovir has the advantage of treating hepatitis B.

Postexposure prophylaxis is given after an HIV-contaminated needlestick. The patient receives full HAART for a month. Abacavir cannot be used because it would take too long to have the HLA type return. Two nucleoside reverse transcriptase inhibitors and an integrase inhibitor are recommended.

In pregnancy, two nucleoside reverse transcriptase inhibitors and a protease inhibitor are recommended. These will reduce the chances of maternal-fetal transmission to less than 1 percent and should be used on all women who are pregnant and HIV positive, regardless of other labs or trimester of pregnancy.

Patients with less than 200 CD4+ cells need TMP/SMX or atovaquone or dapsone if allergic to sulfa drugs as prevention against pneumocystis pneumonia. Pentamidine was once used but has a poor efficacy when aerosolized and given to these patients. If the CD4+ count is less than 50 CD4+ cells, they need prophylaxis also against Mycobacterium Avium-Intracellulare.

Patients who fail pneumocystis prophylaxis may develop the disease and will have dry cough, hypoxia, dyspnea, and an elevated LDH level. The best test is a CXR but the most accurate is a bronchoalveolar lavage. Treatment is with IV TMP/SMX, IV pentamidine, atovaquone (if mild), IV clindamycin/primaquine. Dapsone is only used for prevention. IV steroids will help if severe.

Toxoplasmosis presents with headache, nausea, vomiting, and some focal neurologic signs. There will be a contrast-enhancing lesion on CT of the head. Treatment is with pyrimethamine and sulfadiazine for 2 weeks before repeating the CT with contrast. If not shrinking, perform a brain biopsy.

Cytomegalovirus can be seen with CD4+ counts of less than 50 cells/microliter. The patient will have blurry vision with the diagnosis based on an ophthalmoscope evaluation. There will be lesions on exam. The treatment of choice is IV ganciclovir and foscarnet with oral valganciclovir until the CD4+ count rises.

Cryptococcus can be seen wit CD4+ cells less than 50, along with fever and headache. A lumbar puncture is the test of choice, showing lymphocytosis in the CSF. The most accurate test is the cryptococcal antigen test (95 percent accurate and sensitive). Treatment is with amphotericin B and 5-FC, followed by fluconazole. The fluconazole is given until the CD4+ count rises. When and if this happens, only the retroviral therapy needs to be given.

Progressive focal leukoencephalopathy (PML) can be seen with a CD4+ count of less than 50. It can be tested for with a CT or MRI of the brain. There is no ring enhancement of the brain lesions. The PCR evaluation for the JC virus is most accurate. There is no treatment except to give HAART to bring up the CD4+ count.