INFECTION

Case 45 HIV & AIDS

- HIV infects the helper T cells of the immune system, which are defined by the presence of the cell-signaling
protein CD4, & causes a decline in both their # & their effectiveness. This decline in functional helper T
cells disables the cell-mediated arm of the immune system & leaves the body vulnerable to infection from
multiple opportunistic organisms.
- Acquired immunodeficiency syndrome (AIDS): this advanced stage of the HIV infection, in which
such opportunistic infections occur w/ specific criteria for its designation.
- HIV-1 is more common worldwide, whereas HIV-2 has been reported in western Africa, Europe,
South America & Canada.
- HIV is transmitted from person to person through contact w/ infected blood & body fluids.
o The risk of transmission can be reduced by the proper & consistent use of latex condoms.
B/c HIV can pass through lambskin condoms, these are not recommended.
o Circumcision has also been shown to decrease the rate of HIV transmission.
- Sharing needles by IV drug users is the 2nd most common source of transmission of HIV.
- Vertical transmission from an infected woman to her baby has been found to occur during
pregnancy, during the process of delivery of her baby, & from breast-feeding.
- The risk of transmission to health-care workers is low & is related to the viral load of the patient, the
amount of blood to which the worker is exposed, & the depth of the inoculum.
o Postexposure risk of developing HIV infection can be reduced by immediate & careful
cleaning of the exposure/puncture site along w/ postexposure prophylactic (PEP)
treatment w/ antiviral therapy.
- The primary infection is known as acute seroconversion syndrome, as the symptoms are thought to
be related to the development of antibodies to the virus. Following the resolution of the primary
infection symptoms, there is a period of clinical latency. While the patient is asymptomatic during
this period, a relentless decline in helper T-cell # & immune fxn usually occurs in the untreated pt,
w/ the result that many pts initially present w/ profound immunodeficiency & opportunistic
infections.
- For classification purposes, HIV-infected pts can be defined w/ both a clinical & laboratory category.
o 1. CD4 count of 500 cells/L or more
o 2. CD4 count of 200 to 499 cells/L
o 3. CD4 count of less than 200 cells/L
o Clinical category A includes asymptomatic HIV infection, primary HIV infection, &
persistent generalized lymphadenopathy. Persistent generalized lymphadenopathy is
defined as enlarged lymph nodes involving at least 2 noncontiguous sites other than
inguinal nodes.
o Clinical category B infections are symptomatic conditions in an HIV-infected persons that are
either indicative of a defect in cell-mediated immunity or that have a course of management
complicated by HIV infections.
o Clinical category C infections are AIDS-defining illnesses. The presence of a CD4 cell count
of less than 200 cells/L, w/ or w/out symptoms, is also considered diagnostic of AIDS.
- For classification purposes, a patients HIV is defined by the highest clinical category in which the
patient has every qualified.
- The standard screening test for HIV infection is the detection of HIV antibodies using the enzyme-
linked immunosorbent assay (ELISA). Samples that are repeatedly positive on ELISA testing must
be confirmed by Western blot testing. The Western blot test is an electrophoresis that detects
antibodies to HIV antigens of specific molecular weights.
- HIV is reportable to local health authorities, but partner notification laws vary by state, so it is
important to know the local regulations.
- Screening for other sexually transmitted diseases should be performed initially & repeated, if
needed, b/c of any ongoing risks identified.
- W/out antiretroviral therapy, AIDS is a universally fatal disease.
- B/c of the complexity of treatment regimens & frequently changing treatment guidelines,
patients w/ HIV/AIDS should be referred, in almost all cases, to a physician w/ expertise in
 treating these conditions.
- Prophylactic treatments to reduce the risk of infection are also important in immunosuppressed
patients.
o Prophylaxis against P jiroveci pneumonia should be instituted using TMP-SMX when the CD4
count falls to less than 200 cells/L & Mycobacterium avium-intracellulare complex
prophylaxis, using azithromycin or
clarithromycin, is recommended if the CD4 count falls to less than 75 cells/L.

. Case 48 Fever & Rash:

- History of fever, rash that is diffuse, erythematous papules. Most likely due to roseola, caused by
human herpes virus 6 (HHV-6). HHV-6 is a ubiquitous virus that infects most children before the age
of 3 yrs. The virus has an incubation period of 1 2 wks & causes a prodromal illness associated w/
mild respiratory symptoms & a high fever.
o Following defervescence, a characteristic rash appears suddenly. It is an erythematous
maculopapular eruption that starts on the trunk & spreads rapidly to the extremities
sparing the face.
- Enanthem: an eruption on a mucous membrane as a symptom of disease.
- Exanthem: an eruption on the skin as a symptom of a disease.
- Immunization does not guarantee immunity but may result in a less-severe presentation of the
disease.
- Varicella zoster virus is a highly contagious virus that causes 2 clinical syndromes.
o Chicken pox is the more common childhood infection. A typical case of chicken pox includes
a fever & a rash, which tends to develop in clusters. The initial exanthema is often papules or
vesicles on an erythematous base. The vesicles then progress to shallow, crusted erosions.
Antiviral therapy using acyclovir, valacyclovir, or famcyclovir may shorted the course of
illness in pts older than 2 yrs of age if started w/in 24 hours of
onset.
o The varicella vaccine is a live, attenuated virus & should not be given to the
immunocompromised or pregnant pts.
o Shingles or herpes zoster, is a reactivation of the varicella virus, which can remain dormant
in a dorsal root ganglion following the initial infection. The reactivated virus causes a
vesicular eruption, usually along a single dermatome that does not cross the midline. The
rash can be extremely painful & can result in a painful, postherpetic neuralgia.
- Parvovirus B19 causes a characteristic syndrome known as erythema infectiousm or fifth disease.
This virus tends to infect children younger than 10 yrs of age & occurs most commonly in the winter
or spring.
o The child usually has a prodrome of mild fever & upper respiratory symptoms before
outbreak of the rash. The rash usually starts as confluent erythematous macules on the
face, which usually spares the nose & periorbital regions. This gives the classic slapped
cheek appearance.
- Group A Beta-hemolytic Streptococcus (GAS) can cause the rash of scarlet fever which usually
starts about 2 days after the onset of sore throat. The rash consists
NOT DONE.