1/#IDTwitter #Tweetorial alert! Inspired by a fantastic @HoustonAETC talk by our very own APD @PrathitKulkarni!
Contributors: @MannyGuajardoMD @MelanieGoebelMD
Contributors: @MannyGuajardoMD @MelanieGoebelMD
https://twitter.com/HoustonAETC/status/1301959512790892545?s=20
2/You're seeing a 52YO man with new diagnosis of HIV in clinic, no co-morbidities. Risk factors include multiple unprotected sexual encounters (♂️♀️). Thorough review of systems and exam are unrevealing.
What lab and imaging tests would you order at this visit?
What lab and imaging tests would you order at this visit?
3/Start with some basic labs:
✔️CD4 cell count and %
✔️HIV viral load
✔️CBC w/diff
✔️CMP
✔️Urinalysis
✔️CD4 cell count and %
✔️HIV viral load
✔️CBC w/diff
✔️CMP
✔️Urinalysis
4/Look for co-infections:
🦠Syphilis (Trep Ab or RPR)
🦠Gonorrhea/chlamydia (urine, rectal, pharyngeal NAAT)
🦠TB (TST or IGRA)
🦠Viral hepatitis (A/B/C)
🦠Toxoplasma IgG
+/- CMV IgG 👇
doi.org/10.1093/cid/ci…
🦠Syphilis (Trep Ab or RPR)
🦠Gonorrhea/chlamydia (urine, rectal, pharyngeal NAAT)
🦠TB (TST or IGRA)
🦠Viral hepatitis (A/B/C)
🦠Toxoplasma IgG
+/- CMV IgG 👇
doi.org/10.1093/cid/ci…
5/Obtain a baseline HIV genotype:
🔸In USA, 16% of treatment-naïve PLWH may have transmitted resistance!
🔸NNRTI resistance > NRTI & PI
🔸Transmitted INSTI resistance still rare ➡️ routine testing not recommended
ncbi.nlm.nih.gov/pmc/articles/P…
🔸In USA, 16% of treatment-naïve PLWH may have transmitted resistance!
🔸NNRTI resistance > NRTI & PI
🔸Transmitted INSTI resistance still rare ➡️ routine testing not recommended
ncbi.nlm.nih.gov/pmc/articles/P…
6/Screen for risk of severe adverse drug reactions:
💊HLA-B*5701 haplotype ➡️ high risk for abacavir hypersensitivity ➡️ avoid at all cost
💊G6PD deficiency ➡️ avoid dapsone, primaquine, +/- sulfa (some caveats 👇)
academic.oup.com/cid/article/58…
💊HLA-B*5701 haplotype ➡️ high risk for abacavir hypersensitivity ➡️ avoid at all cost
💊G6PD deficiency ➡️ avoid dapsone, primaquine, +/- sulfa (some caveats 👇)
academic.oup.com/cid/article/58…
7/Back to the case…
>>CD4 returns at 35 cells/µL<<
What OI would you screen for in this asymptomatic patient?
>>CD4 returns at 35 cells/µL<<
What OI would you screen for in this asymptomatic patient?
8/Answer: Cryptococcus ➡️ check serum CrAg
Asymptomatic antigenemia is present in 4.3% of PLWH when CD4 <50!
For other OIs, evaluation should be directed by symptoms and clinical assessment.
Asymptomatic antigenemia is present in 4.3% of PLWH when CD4 <50!
For other OIs, evaluation should be directed by symptoms and clinical assessment.
9/Don't forget about age-appropriate cancer screening.
Since PLWH have ⬆️ risk for HPV-associated cancers ➡️ consider annual cervical/anal pap smears.
For our patient (52YO, MSM), screen for:
🔸 anal cancer
🔸 colorectal cancer
🔸 +/- prostate cancer
Since PLWH have ⬆️ risk for HPV-associated cancers ➡️ consider annual cervical/anal pap smears.
For our patient (52YO, MSM), screen for:
🔸 anal cancer
🔸 colorectal cancer
🔸 +/- prostate cancer
10/Evaluate for baseline metabolic disorders:
🔸HbA1c
🔸Fasting lipid levels
🔸DEXA scan (in postmenopausal women and men >50YO)
🔸HbA1c
🔸Fasting lipid levels
🔸DEXA scan (in postmenopausal women and men >50YO)
11/Why DEXA scan?
Low BMD in PLWH is common!
>>Pathophys<<
HIV T-cell activation leads to ⬆️proinflammatory cytokines & RANKL expression ⬆️osteoclast activity ⬆️osteoblast apoptosis
HIV Outpatient study showed ⬆️rates of bone fx incidence among PLWH.
academic.oup.com/cid/article/52…
Low BMD in PLWH is common!
>>Pathophys<<
HIV T-cell activation leads to ⬆️proinflammatory cytokines & RANKL expression ⬆️osteoclast activity ⬆️osteoblast apoptosis
HIV Outpatient study showed ⬆️rates of bone fx incidence among PLWH.
academic.oup.com/cid/article/52…
12/In general... start ART as soon as possible!
But delay in:
💊 Cryptococcal meningitis
💊 TB meningitis
But delay in:
💊 Cryptococcal meningitis
💊 TB meningitis
13/Quick word about vaccines…
💉Consider delaying until CD4>200 for more robust immune response
💉 Live vaccines contraindicated when CD4<200
💉Consider delaying until CD4>200 for more robust immune response
💉 Live vaccines contraindicated when CD4<200
14/Check out these 🔥sources for more info!
HIV Guidelines:
🔸Prime Care: doi.org/10.1093/cid/ci…
🔸OIs: tinyurl.com/y4xf4oej
🔸Treatment: tinyurl.com/yxttqlx7
Other:
🔸hiv.uw.edu
🔸hivdb.stanford.edu
🔸hiv-druginteractions.org
HIV Guidelines:
🔸Prime Care: doi.org/10.1093/cid/ci…
🔸OIs: tinyurl.com/y4xf4oej
🔸Treatment: tinyurl.com/yxttqlx7
Other:
🔸hiv.uw.edu
🔸hivdb.stanford.edu
🔸hiv-druginteractions.org
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