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HIV-INFECTION
Laboratory diagnostics
Specific diagnostics. In Russia standard inspection on the HIV-infection now
begins with statement IFA (immunofermenative analysis), then specificity of antibodies
confirm in immune blotting. Detection of a genetic material of a virus in the polymerase
chain reaction (PCR) is possible.
Antibodies to the HIV at 90-95 % of the infected appear within 3 months after
infection (the earliest term - 2 weeks), at 5-9 % - within 6 months, at 0,5-1 % - in later
terms.
Nonspecific diagnostics. Be investigated of cellular immunity, first of all -
definition of absolute and relative maintenance of CD4-lymphocytes (helpers), CD8-
lymphocytes (suppressors) and their correlation.
At the adult patients who are taking place in a latent stage of disease, level of
СD4-lymphocytes usually exceeds 0,5*109/l. Proof decrease of CD4 is lower than this
level results in transition of HIV-infection in a stage 4А, is lower 0,35*109/l - in a stage
4B, lower 0,2*109/l - in a stage 4C. Decrease of a parameter below 0,05*109/l, down to
full absence is typical for a stage 5. Decrease of quantity of CD4 - cells, as a rule,
outstrips clinical progressing disease a little. On the other hand, sometimes patients with
very low quantity of CD4-cells (even less 0,1*109/l) live within several years.
Treatment
Basis of treatment - purpose of antiretroviral therapy under clinical and laboratory
indications (the control of level of CD4-lymphocytes and concentration in blood RNA of
the HIV - i.e. virus loading is desirable). Antiretroviral preparations (Azidotymidin,
Phosphazid, Didanosid, Lamivudin, Hivid etc.) have various mechanisms of action and
are applied in combinations, in various circuits - depending on a stage of HIV-infection,
the immune status and virus loading.
The unconditional indication to the beginning of antiretroviral therapy are initial
clinical manifestations of the disease (acute HIV-infection 2B, 2C) and a stage of
secondary diseases (4B, 4C) in a phase of clinical progressing.
Laboratory indications to realization of antiretroviral therapy are the decrease of
level of CD4-lymphocytes less than 0,3*109/l (at children till 6 years - individually) or
the increase of concentration of RNA of the HIV in blood, so-called “virus loading”:
• at children in the age of about 30 months - more than 100000 copies in ml,
• at children in the age of than 30 months - more than 20000 copies in ml,
• at adults - more than 60000 copies in ml of blood (parameters are not taken
into account in case of recent inflammatory disease or an inoculation).
If laboratory indications of such level are revealed for the first time for the decision of a
question on expediency of the beginning of antiretroviral therapy will carry out repeated
research with an interval not less than 4 weeks.
To children till 1 year with finally made diagnosis HIV-infection antiretroviral
therapy is appointed irrespective of the clinical, immunological and virologic data. In
stages 2A, 2B and 3 at absence of immunodeficiency and at moderate
immunodeficiency bitherapy to two inhibitors of return transcriptase is carried out.
Treatment of opportunistic infections will be carried out by the appropriate
preparations, after liquidation of acute manifestations of the disease supporting therapy -
with the purpose of chemoprophylaxis of relapses is appointed.
Dispensary supervision over the HIV-infected persons is carried out to a
territorial attribute by the doctor’s consulting room of infectious diseases, and at its
absence - the local doctor. Children and teenagers are observed in children's consultation
at the pediatrist. At the request of the patient dispensary supervision can be carried out
only in the regional Centre on prophylaxis and struggle about AIDS.
At statement of the patient on the account his initial inspection - with the purpose
of confirmation of the diagnosis, an establishment of a stage of the disease, revealing of
secondary and accompanying diseases will be carried out.
According to the current legislation, initial inspection of the patient and in case of
revealing the HIV-infection - the subsequent treatment and supervision should be carried
out from his voluntary informed consent. The pregnant woman has the right to refuse
inspection on the HIV-infection, and in case of its revealing - from realization of
chemoprophylaxis of infection of a fetus, the further supervision and inspection of the
child. Refusal should be made out documentary in an out-patient card. At detection at
the pregnant woman of the HIV-infection she should be acquainted with conditions of
realization of chemoprophylaxis of transfers of the HIV from her to the child during
pregnancy and labor. In case of the consent with conditions the woman makes out “the
Informed consent”, as the official medical and legal document - with own hand, with the
signature; the doctor also signs this document.
Control questions
1. Etiology of the HIV.
2. Name sources of the HIV-infection.
3. List ways of transfer of the HIV-infection.
4. List clinical stages of the HIV on V.I.Pokrovsky (2001г).
5. List variants of current of initial manifestations of the HIV
6. List clinical variants of the 4 stage of secondary diseases of the HIV-infection.
7. Name methods of laboratory diagnostics of the HIV-infections.
8. List antiviral preparations used for treatment of the HIV.
9. Name the clinic-laboratory data at the HIV for purpose of antiviral therapy.
10. Name ways of the prophylaxis of the HIV.
The test.
PROBLEM
In infectious hospital patient P., 28 years, with complaints to a high body
temperature (up to 40°С), a headache, periodic vomiting, a dyspnea has arrived. At
survey: a condition is heavy; he is exhausted, pale, there is acrocyanosis. Peripheral
lymphatic nodes are increased about 1-1,5 sm, mainly in a cervical area, they are dense,
mobile, painless. There is a dyspnea (28 in one minute), at auscultation there is harsh
breathing. Tones of heart are muffled. Pulse is 120 in one minute, weak filling. The liver
comes forward from under the right costal arch on 2,5 sm, the spleen is palpated. The
patient is disoriented in a place, time, the own person. It is revealed right-hand
hemiparesis. Generalized spasms are periodically arisen. There are no meningeal
symptoms. The relative, accompanied the patient, has told, that patient consists on the
account concerning the HIV-infection during 3 years. Deterioration of a condition has
come about 3 weeks back when headaches and high temperature, and then - vomiting,
spasms, disorientation have appeared.
At laboratory research in the immune status significant decrease of quantity of
CD4-lymphocytes (up to 50 cells in mcl) is marked. At research of blood there are
anemia and leucopenia. At realization of computer tomography of a brain in a cortex of
a brain it is revealed a little of annular condensation surrounded by an edematous tissue.
PROBLEM
Patient B., 19 years, the student. He has addressed to the doctor of a polyclinic in
connection with detection within 3-4 months of the increased lymph nodes on a neck.
Objectively: a body temperature is normal. A condition is satisfactory. A skin is of usual
coloring, without a rash. There are traces of intravenous injections on hands. Back-
cervical, supraclavicular and ulnar lymph nodes are increased up to 1 sm, axillary - up to
1,5 sm in diameter; they are of densely - elastic consistence. They are painless. By the
side of internal organs pathology is not revealed. At ultrasonic research of organs of an
abdominal cavity and at radiography of organs of a chest the increase of visceral lymph
nodes is not revealed.
1. What is the provisional diagnosis? Present its substantiation.
2. The plan of inspection.
3. Give the recommendation to the patient.