Infection

Pneumocystis Jiroveci

CD4 Count
< 200

Signs & Symptoms Diagnosis

Fever, cough, dyspnea, pulmonary infiltrates, hypoxemia ( Aa gradient & Pa O2 Increased lactate dehydrogenase, oral thrush

1 Prophylaxis
DOC: TMP/SMX Alternatives: -Dapsone -Dapsone + Pyrimethamine+ folinic acid -Atorvaquone take with food -Aerolized Pentamidine + Respirigard II D/C prophylaxis CD4+ > 200 for 3 months Restart if CD4+ < 200 or reinfection PCP with CD4+ > 200 treat lifetime

Treatment
Mild/ Moderate- Treat 21 dys TMP/ SMX IV or PO Dapsone + TMP PO Clindamycin PO + Primaquin (G6D test) PO Atorvaquone PO Moderate/ Severe Treat 21 dys -TMP/ SMX IV O --Pentamidine IV -Clindamycin IV + Primaquin (G6D test) IV -Atorvaquone PO Adjunctive Corticosteroid TherapyTaper Prednisone 40 mg BID (5dys), 40 mg qd (5dys) , 20 mg qd (11 dys) Induction=2 weeks -Amphotericin B deoxycholate + flucytosine -Liposomal amphotericin B + flucytosine Consolidation- 8 weeks or culture negative Fluconazole

2 Prophylaxis
Same as for Primary

Diagnosis Methamine silver stain CXR- interstitial bilateral infiltrates CT scan-dense pulmonary consolidation

Cryptococcal Meningitis

<100 <50 majority

Fever, malaise, headache Neck stiffness & photophobia Lethargy, altered mental status, memory loss Dissemination systemic signs e.g. Cough & dyspnea (lungs), lesions (skin) Diagnosis India ink stain-CSF Pleocytosis- high lymphocytes, high protein, low to normal glucose CT- thick, mucoid meninges Headache, confusion Motor weakness Fever No TX seizures, stupor and coma Diagnosis Sero positive anti toxoplasma immunoglobulin G CT/MRI/ Radiographic testing ring enhancing

NONE

Maintenance or 2 prophylaxis Fluconazole Continue lifelong or until CD4+ >200 for 6 months on HAART

Toxoplasmic Encephalitis

< 50 <100 common

DOC: TMP-SMX DS QD Alternate -TMP- SMX DS 3 times/ week -Dapsone + Pyrimethamine + folinic Acid -Atorvoquone ( take with food) D/C prophylaxis CD$+ > 200 for 3 months Restart prophylaxis if CD4 <

Treatment = 6 weeks improvement 10 dys DOC : Sulfadiazine + pyrimethamine + leucovorin Alternative Clindamycin + pyrimethamine + leucovorin ( sulfur allergy) TMP/SMX IV Atorvoquone + pyrimethamine +

DOC : Sulfadiazine + pyrimethamine + leucovorin Alternative Clindamycin + pyrimethamine + leucovorin ( sulfur allergy) Atorvoquone + pyrimethamine D/C when CD4+ > 200 for 6 mnths Restart if CD4+ < 200

lesion Brain Biopsy

100-200

leucovorin Adjunctive Corticosteroid Therapy for focal lesions with edema DOC dexamethasone IV D/C ASAP clinically

Infection
Mycobacteriu m Avium Complex

CD4 Count
<50

Signs & Symptoms Diagnosis

Fever, chills, night sweat Abdominal pain, diarrhea Weakness, anemia Serum alkaline Phosphatase Diagnosis +ve MAC culture from site + blood Bone biopsy Stool culture BAL

1 Prophylaxis
DOC- Azithromycin Alternatives -Clarithromycin -Rifabutin D/C Prophylaxis CD4+ > 100 for 3months Restart if CD4+ < 50

Treatment
Treatment = 12 months DOC: Clarithromycin + ethambutol + rifabutin ( add 3rd agent when CD4+ < 50 Change to Azithromycin and rifabutin with PIs & NNRTs CYP 450 interactions For sever disease add Streptomycin IV or amikacin PO D/C after 12 mnths if ve blood culture & CD4+ > 100 for 3 mnths

2 Prophylaxis
None

Cytomegalovi rus

< 50

15-46% HIV patients Retinitis, colitis, esophagitis, pneumonitis, encephalitis Painless loss of visionflashing lights and floaters Diagnosis Retinal changes- fluffy, white perivascular exudates and hemorrhage

Gancyclovir- Not recommended (may induce resistance)

Induction therapy- 21 days Immediate Site threatening Ganciclovir intraocular implant valgancyclovir PO Peripheral Lesions -14- 21 days Valgancyclovir PO Alternative Foscarnet IV Cidoffovir IV Gangcilovir IV

Maintenance Therapy after 21 dys DOC: ganciclovir PO + intraocular gancyclovir Until immune reconstitution Alternatives Gancyclovir PO for small lesions Foscarnet IV Cidofavir q 2 weeks + Probenicid with hydration Gancilovir IV 5dys/week Continue until immune reconstitution CD4+ > 100 150

Suppression of HIV viral load Adequatevision Monthly eye exam while on medication then q 3 months