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P: Plan Diagnostic Evaluation During the initial evaluation, check complete blood count (CBC) and differential, sputum gram stain, sputum AFB stain and culture (see below) blood cultures, and chest x-ray. For patients with lymphadenopathy, consider fine needle aspiration biopsy for bacterial and AFB stains and culture, and cytologic evaluation. For patients with meningitis or central nervous system abnormalities, perform lumbar puncture (LP) and cerebral spinal fluid (CSF) analysis including cell count, protein, glucose, AFB smear, AFB, bacterial and fungal cultures. If focal neurologic abnormalities are present, obtain computed tomography (CT) scan of the head to rule out mass lesion before doing the LP. Perform other diagnostic tests as suggested by the clinical presentation. Pulmonary TB can be associated with any chest xray appearance, including a normal x-ray. However, the chest x-ray classically demonstrates upper-lobe infiltrates with or without cavities. Patients with HIVassociated immunosuppression are more likely to have atypical chest x-rays, including absence of cavities, lower-lobe disease, hilar or mediastinal adenopathy, and pleural effusions. In disseminated TB, the chest x-ray may show a miliary pattern with small nodules (“millet seeds”) scattered throughout both lungs. Suspected TB should be evaluated aggressively. Diagnosis of TB should include identification of the organism in stained sputum smears or stains of biopsied tissue and confirmed by culture or nucleic acid amplification (such as polymerase chain reaction). All positive cultures should be tested for drug susceptibility. Proof of the diagnosis is important because other opportunistic diseases can mimic TB, and other mycobacterial infections requiring different treatment can occur in HIV-infected persons. Drug susceptibility testing is necessary because improper treatment of drug-resistant TB will lead to treatment failure, more severe drug resistance within the patient, and increased risk of transmission of drug-resistant TB. A presumptive diagnosis of TB is made on acid-fast stains of expectorated sputum; 3 specimens should be sent for acid-fast staining and mycobacterial culture on 3 successive days (preferably first morning specimens). Sputum induction with nebulized saline can be used for patients who do not have spontaneous sputum Section 6—Disease-Specific Treatment | 6–67 production. Patients with suspected pulmonary TB and negative sputum smears should undergo bronchoscopy and transbronchial biopsy (which is more sensitive than bronchoalveolar lavage for TB). Young children cannot not produce sputum, so gastric lavage on 3 successive mornings can be performed to obtain swallowed sputum for smear (although false-positive smears occur) and culture. The diagnosis of extrapulmonary TB generally requires microscopic examination of tissue and culture. An aspirate of a suspect lymph node will often be positive on smear, on histopathologic examination, and on culture. Specimens of organs with suspected TB can be obtained by CT-guided aspiration and biopsy, liver biopsy, bone marrow biopsy, “blind” needle biopsies of pleura or peritoneum, or thoracoscopy or laparoscopyguided biopsies of pleura or peritoneum. At times an open surgical procedure is required to obtain appropriate specimens. Blood cultures for mycobacteria (using appropriate mycobacterial media rather than standard blood culture media) may be positive in disseminated TB; the technique is the same as in culturing blood for M avium complex organisms. Urine culture is used to diagnose renal TB, which is rare among HIV-infected persons. Some laboratories will perform a nucleic acid detection test on positive sputum smears and can confirm MTB in positive smears within 1 or a few days. The test is not sufficiently sensitive to use on negative smears, and drug sensitivity testing requires growth in culture. Initial growth may occur within 3-8 weeks. A nucleic acid probe can confirm a positive culture as MTB within a few days of culture growth; otherwise speciation may take several weeks. Susceptibility testing generally takes 3-4 weeks after the initial culture growth, depending on the laboratory procedures used. Note that a positive TST result indicates TB infection but does not prove active disease (see chapter Latent Tuberculosis). Similarly, a negative test can occur in HIV-infected persons with active TB and this was common among persons with disseminated TB prior to the HIV epidemic. A positive TST provides supporting evidence of TB disease; a negative test is not as informative in HIV-infected persons.
6–68 | Clinical Manual for Management of the HIV-Infected Adult/2006 Respiratory Precautions Respiratory infection control precautions should be implemented for HIV-infected patients with an undiagnosed chronic cough or undiagnosed inflammatory infiltrate on chest x-ray. Individual institutions have specific guidelines that should be followed; usually patients are housed in single negativepressure rooms and persons entering the rooms are required to wear individual protective respirators. If 3 sputum smears are negative on acid-fast staining, or if a single deep specimen (bronchial lavage or tracheal aspirate) is smear negative, infectious TB is unlikely and respiratory precautions can be discontinued. Patients who are highly suspect for MTB and lack an alternative diagnosis should be kept on precautions and empiric treatment may be started. Persons who have responded to treatment for an alternative diagnosis (eg, bacterial pneumonia) and who cannot produce the requisite 3 sputum samples, may be released from the TB precautions. The impact of TB transmission is severe in a health care setting, where immunosuppressed persons may be exposed. Children aged
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Table of Contents Clinical Manual f
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Preface—About this Manual | Clini
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Previous Editions Atlanta Contribut
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♦ ♦ ♦ ♦ ♦ | Clinical Manu
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Initial Physical Examination Backgr
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Genitals/Rectum • Inspect the gen
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Initial and Interim Laboratory and
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Section 1—Testing and Assessment
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Patient Education ♦ ♦ ♦ ♦ D
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Section 2—Health Maintenance and
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References ♦ ♦ ♦ ♦ ♦ ♦
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Occupational Postexposure Prophylax
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P: Plan Laboratory Testing Provide
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For hepatitis C, no recommended pro
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as hepatitis C or another sexually
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for treatment is appropriate, and b
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contact with the patient. Patients
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tablet daily of trimethoprim-sulfam
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Opportunistic Infection Prophylaxis
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Discontinuing Primary Prophylaxis P
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Latent Tuberculosis Background Late
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INH may cause liver toxicity and it
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Patient Education ♦ ♦ ♦ ♦
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Reducing Maternal-Infant HIV Transm
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Some states require written informe
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contraindicated during pregnancy be
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Section 3—Antiretroviral Therapy
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Nelfinavir (Viracept) Adequate drug
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Patient Education ♦ ♦ ♦ ♦
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Section 4—Complications of Antire
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♦ ♦ ♦ Toronto General Hospita
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Adverse Reactions to HIV Medication
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♦ ♦ ♦ ♦ ♦ Vital signs: No
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egimen, symptoms of fatigue could i
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Recreational Drugs and Antiretrovir
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Section 4—Complications of Antire
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LSD, Mescaline, Psilocin, and Methy
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Immune Reconstitution Syndrome Back
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A: Assessment In the appropriate cl
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♦ ♦ ♦ ♦ ♦ Navas E, Martin
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Eye Problems Background The immunos
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of
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Fever Background Although fever may
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Headache Background Headache may ha
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Lymphadenopathy Background Lymphade
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Treatment Treatment will depend on
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Neurologic Symptoms Background The
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Pulmonary Symptoms Background Short
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Treatment Once the diagnosis is mad
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Candidiasis, Oral and Esophageal Ba
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Maintenance therapy Use caution whe
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Cervical Dysplasia Background Cervi
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Patient Education ♦ ♦ ♦ ♦ P
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Page 254 and 255: Cryptosporidiosis Background Crypto
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Page 266 and 267: Gonorrhea and Chlamydia Background
Page 268 and 269: Treatment of Gonorrhea Treatment op
Page 270 and 271: Hepatitis B Infection Background He
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Page 274 and 275: Hepatitis C Infection Background He
Page 276 and 277: pregnancy. Ribavirin is teratogenic
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Page 294 and 295: Mycobacterium avium Complex Backgro
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Page 338 and 339: Toxoplasmosis Background Toxoplasma
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Page 346 and 347: Oral Health Background Examination
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Periodontal Disease Background The
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Oral Hairy Leukoplakia Background O
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Oral Ulceration Background Oral ulc
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Oral Warts Background Oral warts ar
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Anxiety Disorders Background Anxiet
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Patient Education ♦ ♦ Behaviora
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Insomnia Background Insomnia is a c
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Suicidal Ideation Background Transi
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Section 8—Neuropsychiatric Disord
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P: Plan ♦ ♦ ♦ ♦ ♦ Check t
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Correctional Settings Background Ca
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Adherence Adherence is one of the m
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Karnofsky Performance Scale Backgro
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