NMS Q&A Family Medicine

Acquired Infectious Diseases in Primary Care 187but would pose the dilemma of accounting for a clinicalpicture with more than one major diagnosis. In immunocompromisedpatients, this infection must be treated for4 to 6 weeks after cessation of symptoms. The first drug ofchoice is pyrimethamine given 25 to 100 mg daily plussulfadiazine given 1 to 1.5 g 4 times daily. Folic acid isadded to prevent marrow suppression.8. The answer is A. CMV retinitis occurs in AIDS patientswith CD4 counts under 50/ L. It must be treated to preventor retard the progression of the retinitis and to preventretinal detachment. Treatment is by antiviral agents, suchas ganciclovir, valganciclovir, and foscarnet. Cotton woolspots, different from the white fluffy exudates of CMV recognizedby ophthalmologists, are benign and self-limiting.9. The answer is E. Candidiasis is highly suggestive ofimmunoincompetence in adults, particularly in theesophagus, trachea, bronchi, or lungs. Of interest is thateven oral candidiasis in an HIV-infected person stronglypresages progression to AIDS, even correcting for CD4count. Only 75% of patients with esophageal candidiasishave oral candidiasis so that oral candidiasis is not a reliableconfirmatory indicator for esophageal candidiasis.Luwig angina is unusual and may well be suspicious forimmunoincompetence but presents with a cellulitisapparent by external examination of the neck. The clinicalpicture does not include a description of herpetic or aphthousulcers.10. The answer is D. Lymphadenopathy. Fever, lymphadenopathy,sore throat, rash, and headache are typicalsymptoms of an acute infection with HIV. During theacute phase, none of the stigmatic conditions associatedwith HIV infection have yet appeared. The other presentedentities are seen in later stages of HIV infection.11. The answer is A. Saliva, a fluid functionally designedfor secretion onto the exterior surface, is not an HIV riskunless there is a break in the mucosa that exudes bloodinto the saliva; thus, the shared toothbrush is a risk. Blood,semen, vaginal secretions, and synovial, pleural, peritoneal,and cerebrospinal fluids are all felt to contain significantamounts of the virus in an infected individual. Urine,saliva, perspiration, and even vaginal secretions normally(i.e., in the absence of contiguous breaks in skin ormucosa) pose little to no risk as media of transmission.Thus, fluids whose normal function is entirely within thebody’s envelope of skin and mucosae are not normallymedia of passage of the HIV virus.12. The answer is C. AIDS dementia complex is a diagnosisof exclusion (see Question 5 and its discussion).Alzheimer disease may remit and exacerbate regardingcognitive changes but motor problems in Alzheimer diseasefollow a steady but slowly down hill course.13. The answer is E. The statement is incorrect in that acount of any number of copies is not necessarily a confirmationof HIV. If the viral load is reported as a low level,say, 500 copies, it may be a false-positive result. All otherstatements regarding the use and applications of viralload measurements are true.14. The answer is D. A seropositive asymptomatic patientwith CD4 count 1000 mcL and convalescent hepatitis A isnot an indication for initiation of ART, assuming no otherindications exist. However, infection with hepatitis B C,risk factors for non-AIDS-associated cancers or for heartdisease are each indication as HIV replication is thought tohasten progression of those conditions. Rapidly droppingCD4 counts or viral load at or above 100,000 mcL are firmindications as are symptoms that constitute grounds for adiagnosis with or without corroboratory laboratory evidence.Other indications are the clinical presence of the followingOIs: candidiasis of esophagus or lower respiratorytract; extrapulmonary cryptococcosis; cryptosporidiosiswith diarrhea lasting longer than 1 month; CMV in organsother than spleen or lymph nodes; mucocutaneous ulcer ofherpes simplex virus (HSV) infection longer than 1 monthor HSV bronchitis, pneumonitis, or esophagitis; Kaposisarcoma in persons over 60 years of age; atypical mycobacteriaof other than lungs, skin, or cervical or hilar nodes;pneumocystis jiroveci pneumonia; and progressive multifocalleukoencephalopathy and cerebral toxoplasmosis.15. The answer is C. Draw baseline serologic studies forhepatitides B and C and HIV; then institute a 4-weekcourse of Combivir and repeat the serologic studies at 6weeks, 12 weeks, and 6 months. The situation would bevery different if there had been a single known source, asoccurs in a hospital setting, where both the source and theexposed patients could be tested or even retested. In thatcase, the exposed worker is simply tested in the manneroutlined while the source patient is observed after baselinetesting or retested if necessary and possible. Indeed,the risks, even in the vignette presented, are minimal, butthe rare chances of disease, particularly HIV, are so immensethat most clinicians would recommend the course of ART(which protects also against hepatitis B). Combivir isavailable as 150 mg lamivudine/300 mg zidovudine, takentwice daily for a recommended period of 4 weeks.ReferencesKatz ML , Zolopa AR , Hollander H . HIV infection . In: TierneyLM , McPhee SJ , Papadakis , MA , eds. Medical Diagnosis andTreatment . 45th ed . Lange ; 2006 .McPhee SJ , Papadakis MA . Current Medical Diagnosis and Treatment2010 , 49th ed . New York/Chicago : McGraw-Hill/Lange ;2010 .Weinstock MB , Crane R . Adult acquired immune deficiency syndrome. In: Rudy DR , Kurowski K , eds. Baltimore : Williams &Wilkins ; 1997 : 481 – 500 .