Rosen & Barkin's 5-Minute Emergency Medicine Consult (350 page)

• For pulmonary symptoms with HIV:
  
  • Pulmonary emboli
    
  • Pulmonary HTN
    
  • TB
    
  • Pneumonia: Bacterial, fungal, viral
    
  • Pulmonary malignancies
    
  • Lymphocytic interstitial pneumonitis
    
• For CNS symptoms with HIV:
  
  • Neurosyphilis
    
  • CMV or HSV encephalitis
    
  • Toxoplasmosis
    
  • CNS lymphoma
    
  • Meningitis (bacterial, coccidioidal, etc.)
    
  • Subarachnoid hemorrhage
    
  • Cerebral infarction
    
  • HIV or metabolic encephalitis
    
  • Progressive multifocal leukoencephalopathy
    
• Cardiac symptoms with HIV:
  
  • Cardiomyopathy
    
  • Pericarditis/myocarditis
    
  • Endocarditis
    
  • Acute coronary syndrome
    
  • Pericardial effusion
    
• Oral symptoms with HIV:
  
  • Fungal infection (i.e., candidiasis)
    
  • Viral lesions (HSV, CMV, hairy leukoplakia)
    
  • Bacterial lesions (TB, periodontal disease)
    
  • Autoimmune (salivary gland disease, aphthous ulcers)
    
  • Neoplasm (KS, lymphoma)
    
• Esophageal symptoms with HIV:
  
  • Infectious esophagitis (candida, CMV, HSV)
    
  • Reflux esophagitis
    
• Diarrhea with HIV:
  
  • Medication side effect
    
  • Parasites (Cryptosporidium, Giardia, Isospora)
    
  • Bacteria
    
  • Viral (CMV, HSV, HIV)
    
  • Fungi (histoplasmosis, cryptococcus)
    
  • HIV-associated enteropathy
    
• Hepatomegaly with HIV:
  
  • Hepatitis
    
  • Opportunistic infection (CMV, MAC, TB)
    
• Renal disease with HIV:
  
  • Drug nephrotoxicity
    
  • HIV nephropathy
    
  • Vasculitis
    
  • Obstruction
    

TREATMENT

• Patients who appear to have bacterial infections, appear toxic, or have rapidly progressive symptoms should receive their 1st dose of antibiotics in the ED.
  
• Begin HIV treatment if: Low CD4 (<350) or high viral load, pregnancy, AIDS defining illness or HIV-associated nephropathy (in general, patients with documented primary HIV infection also undergo resistance testing after the diagnosis has been established)
  
• Triple therapy (HAART):
  
  • 1 non-nucleoside reverse transcriptase inhibitors (NNRTI) and 2 nucleoside reverse transcriptase inhibitors (NRTI)
    
  • 1 PI and 2 NRTIs
    
  • Triple NRTI
    
• Postexposure prophylaxis:
  
  • Start therapy within 2 hr if possible and continue for 4 wk
    
  • 2-drug regimen for most exposures:
    
    • Zidovudine + lamivudine (combivir)
      
    • Lamivudine + stavudine
      
    • Stavudine + didanosine
      
  • 3-drug expanded regimen for very high-risk exposure
    
• Toxoplasmosis: Pyrimethamine:
  
  • Sulfadiazine
    
  • Leucovorin
    
  • Steroids for cerebral edema
    
  • Treat for at least 6 wk
    
• Cryptococcal meningitis:
  
  • Amphotericin B
    
  • Flucytosine
    
  • Treat with above for 2 wk, then fluconazole for 8 wk
    
• CMV retinitis: Ganciclovir
  
• Esophageal candidiasis:
  
  • Fluconazole for 14–21 days
    
• MAC: Clarithromycin:
  
  • Ethambutol
    
  • May add rifabutin if severe immunosuppression
    
• PCP:
  
  • Trimethoprim/sulfamethoxazole
    
  • Pentamidine or dapsone for sulfa-allergic patients
    
  • If PaO
    ₂
    <70 mm Hg or A-a gradient >35 mm Hg, add prednisone 40 mg PO BID for 5 days, then taper
    
• Oral candidiasis: Clotrimazole troches
  
• HIV acute demyelinating polyneuropathy: Plasmapheresis
  

• Common medication complications:
  
  • Hypersensitivity reaction: Abacavir
    
  • Pancreatitis:
    
    • Dideoxyinosine
      
    • Dideoxycytidine
      
    • Didanosine
      
    • Lamivudine
      
    • Cotrimoxazole
      
    • Pentamidine
      
    • Ritonavir
      
    • Stavudine
      
    • Zalcitabine
      
  • Peripheral neuropathy:
    
    • Didanosine
      
    • Isoniazid
      
    • Linezolid
      
    • Stavudine
      
    • Zalcitabine
      
  • Kidney stones: Indinavir and Atazanavir
    
  • Hepatotoxicity: All agents to some degree:
    
    • Nevirapine
      
    • Didanosine
      
    • Stavudine
      
  • Lactic acidosis: Stavudine:
    
    • Didanosine
      
  • Stevens–Johnson syndrome:
    
    • Nevirapine
      
    • Atazanavir
      
    • Delavirdine
      
    • Efavirenz
      
    • Cotrimoxazole
      
    • Trimethoprim/sulfamethoxazole
      
  • Hemolytic anemia:
    
    • Dapsone (used for treatment of TB)
      
    • Zidovudine with ribavirin
      
  • Psychosis: Efavirenz
    
  • Hypoglycemia: Pentamidine
    
  • Postural hypotension: Maraviroc
    
  • Hyperlipidemia, truncal obesity, and atherosclerosis: Stavudine:
    
    • Protease inhibitors
      
  • Dilated cardiomyopathy: Zidovudine
    
  • Benign increase in unconjugated bilirubin: Atazanavir and indinavir
    
  • Macrocytic anemia: Zidovudine
    
  • Many cause some hematologic effects, GI upset, and rash
    

FOLLOW-UP

• Unexplained fever with CNS involvement or suspected endocarditis
  
• Neutropenic fever
  
• Hypoxemia (PaO
  ₂
  <70 mm Hg)
  
• Cardiac symptoms suggestive of ACS
  
• Pericardial effusion
  
• Suspected bacterial pneumonia or TB
  
• A change in neurologic status
  
• New-onset seizures
  
• Hemodynamic instability
  
• Inability to ambulate or tolerate oral intake
  
• Intractable diarrhea with dehydration
  

The patient can maintain adequate oral intake, provide self-care, and ambulate.

• Patient should be referred to a primary HIV care provider for initiation of HAART therapy regimen and ongoing care.
  
• Be alert for signs of depression and refer for counseling or psychiatric treatment as this may inhibit treatment compliance.
  
• HIV patients are at higher risk for many malignancies—refer those with concerning symptoms for follow-up.
  

• Immune reconstitution inflammatory syndrome usually manifests within 8 wk of initiation of HAART as symptoms of opportunistic or autoimmune disease.
  
• For occupation exposures, there is a low risk of seroconversion (0.3% for significant percutaneous exposure and 0.09% for mucocutaneous).
  
• HIV patients on HAART should be considered at higher risk for insulin resistance and acute coronary syndrome/CAD, independent of other risk factors.
  
• Measure oxygen saturation after walking in patients with a normal CXR and symptoms of pneumonia to help diagnose PCP.
  
• HIV is an independent risk factor for COPD, pulmonary hypertension, CVA, venous thromboembolic disease, TTP, osteoporosis, and osteonecrosis of the hip.
  

• Belleza WG, Browne B. Pulmonary considerations in the immunocompromised patient.
  Emerg Med Clin North Am
  . 2003;21(2):499–531.
  
• Church JA. Pediatric HIV in the emergency department.
  Clin Ped Emerg Med
  . 2007;8:117–122.
  
• Marco CA, Rothman RE. HIV infection and complications in emergency medicine.
  Emerg Med Clin North Am
  . 2008;26:367–387.
  
• Self W. Acute HIV infection: Diagnosis and management in the emergency department.
  Emerg Med Clin North Am.
  2010;(28):381–392.
  
• Venkat A, Piontkowsky DM, Cooney RR, et al. Care of the HIV-positive patient in the emergency department in the era of HAART.
  Ann Emerg Med
  . 2008;52:274–285.
  

CODES

• 042 Human immunodeficiency virus [HIV] disease
  
• V08 Asymptomatic human immunodeficiency virus [HIV] infection status
  
• 007.4 Cryptosporidiosis
  

BASICS