Clinical Manual for Management of the HIV-Infected ... - myCME.com

5–26 | Clinical Manual for Management of the HIV-Infected Adult/2006
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Malaria
Pelvic inflammatory disease (PID)
Sexually transmitted infections
Autoimmune process
Immune reconstitution syndromes, related to
opportunistic infections, are often associated with
fever. (See chapter Immune Reconstitution Syndrome.)
Drug-induced fever (common culprits include
abacavir, nevirapine, sulfonamides, dapsone,
amphotericin, pentamidine, thalidomide, penicillin,
clindamycin, carbamazepine, phenytoin, barbiturates,
and bleomycin)
P: Plan
Perform laboratory work and other diagnostic studies
as suggested by the history, physical examination, and
differential diagnosis. These may include the following:
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CD4 count (if not done recently) to help with risk
stratification for opportunistic illnesses
Complete blood count (CBC) with differential
Blood cultures (bacterial, mycobacterial, fungal)
Urinalysis, urine culture if UTI symptoms are
present
Liver enzymes, renal panel
Chest x-ray; sinus films if indicated by symptoms
and physical examination findings
If respiratory symptoms and signs are present:
sputum evaluation (Gram stain and acid-fast
bacilli smear, evaluation for PCP), with culture of
sputum for bacterial pathogens, acid-fast bacilli, and
fungi as indicated; consider sputum induction or
bronchoscopy if indicated
Serum cryptococcal antigen if CD4 count is
101° F, for >3 weeks without
findings on initial workup, more intensive workup
may be needed, such as lumbar puncture, other scans
or biopsies; consult with a specialist in infectious
diseases or an HIV expert to determine whether
hospitalization or other laboratory tests are needed.
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For patients taking abacavir or nevirapine, rule
out hypersensitivity reactions (see chapter Adverse
Reactions to HIV Medications).
Once a diagnosis is made, appropriate treatment should
be initiated. In seriously ill patients, presumptive
treatment may be started while diagnostic tests are
pending. In some cases, the source of fever cannot be
identified. Consult with an HIV expert.
Symptomatic treatment may include NSAIDs,
particularly naproxen (Naprosyn, Aleve) because it
can be administered twice daily; acetaminophen; and
analgesics. Monitor for gastrointestinal adverse effects
with NSAIDs. Cold compresses also can be used to
relieve fever symptoms. Refer to a dietitian to avoid
weight loss during the hypermetabolic state. See Section
6: Disease-Specific Treatment, in this manual if an HIVrelated
cause is identified.
Patient Education
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Patients should report any new fever to their
health care providers. They should measure their
temperatures using a thermometer at home in order
to report actual temperatures.
Patients should know that fever is usually a sign that
their bodies are battling an infection. Their health
care providers may need to do special tests to find
out what could be causing the fever.
Many over-the-counter remedies are available to
treat fevers. Patients should check with their care
providers before taking these. Acetaminophencontaining
products (eg, Tylenol) are generally well
tolerated. Persons with liver disease should use
acetaminophen only as prescribed. NSAIDs (eg,
ibuprofen, naproxen, Advil, Motrin, Aleve) may
also be used, but can cause gastrointestinal adverse
effects, especially if taken without food. Patients
should let their care providers know if they need to
take these medicines for more than 2 or 3 days.
References
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Bartlett JG, Gallant JE. 2005-2006 Medical
Management of HIV Infection. Baltimore: Johns
Hopkins University Division of Infectious Diseases;
2005. Available online at hopkins-aids.edu.
Cross KJ, Hines, JM, Gluckman SJ. Fever of
Unknown Origin. In: Buckley RM, Gluckman
SJ, eds. HIV Infection in Primary Care 2002.
Philadelphia: WB Saunders; 2002.