A 34-year-old man with a past history of HIV infection presents to the Emergency Department with watery diarrhoea. Cryptosporidium infection is confirmed on ZN staining.
What is the most suitable management?
Correct Answer C: Supportive therapy is the mainstay of treatment in Cryptosporidium diarrhoea.
HIV: diarrhoea:
Diarrhoea is common in patients with HIV. This may be due to the effects of the virus itself (HIV enteritis) or opportunistic infections.
Possible causes:
Cryptosporidium is the most common infective cause of diarrhoea in HIV patients. It is an intracellular protozoa and has an incubation period of 7 days. Presentation is very variable, ranging from mild to severe diarrhoea. A modified Ziehl-Neelsen stain (acid-fast stain) of the stool may reveal the characteristic red cysts of Cryptosporidium.
Treatment is difficult, with the mainstay of management being supportive therapy* Mycobacterium avium intracellulare is an atypical mycobacteria seen with the CD4 count is below 50. Typical features include fever, sweats, abdominal pain and diarrhoea. There may be hepatomegaly and deranged LFTs.
Diagnosis is made by blood cultures and bone marrow examination. Management is with rifabutin, ethambutol and clarithromycin.
*nitazoxanide is licensed in the US for immunocompetent patients
Which one of the following is a live attenuated vaccine?
Correct Answer A: Vaccinations It is important to be aware of vaccines which are of the live-attenuated type as these may pose a risk to immunocompromised patients. The main types of vaccine are as follows:
Live attenuated vaccines:
Inactivated preparations:
Detoxified exotoxins:
Extracts of the organism/virus (sometimes termed fragment)**:
Notes:
*whole cell typhoid vaccine is no longer used in the UK
**may also be produced using recombinant DNA technology
A 22-year-old woman who is an immigrant from Malawi presents for review as she thinks she is pregnant. This is confirmed with a positive pregnancy test. She is known to be HIV positive.
Which one of the following should not be part of the management plan to ensure an optimal outcome?
Correct Answer C: The 2008 BHIVA guidelines suggest vaginal delivery may be an option for women on HAART who have an undetectable viral load but whether this will translate into clinical practice remains to be seen.
HIV and pregnancy:
With the increased incidence of HIV infection amongst the heterosexual population there are an increasing number of HIV positive women giving birth in the UK. In London the incidence may be as high as 0.4% of pregnant women. The aim of treating HIV positive women during pregnancy is to minimize harm to both the mother and fetus, and to reduce the chance of vertical transmission.
Factors which reduce vertical transmission (from 25-30% to 2%):
Screening:
Antiretroviral therapy:
Mode of delivery:
Neonatal antiretroviral therapy:
*The 2008 BHIVA guidelines suggest vaginal delivery may be an option for women on HAART who have an undetectable viral load but whether this will translate into clinical practice remains to be seen
A 34-year-old man from Zimbabwe is admitted with abdominal pain to the Emergency Department. An abdominal x-ray reveals urinary bladder calcification.
What is the most likely cause?
Correct Answer E: Schistosoma haematobium causes haematuria.
Schistosomiasis is the most common cause of bladder calcification worldwide.
Schistosomiasis, or bilharzia, is a parasitic flatworm infection. The following types of schistosomiasis are recognised:
Schistosoma haematobium:
This typically presents as a 'swimmer's itch' in patients who have recently returned from Africa. Schistosoma haematobium is a risk factor for squamous cell bladder cancer.
Features:
Management:
Which one of the following best describes the action of aciclovir?
Correct Answer B:
Antiviral agents:
Aciclovir:
Ribavirin:
Interferons:
Amantadine:
Anti-retroviral agent used in HIV:
- Nucleoside analogue reverse transcriptase inhibitors (NRTI)
- Non-nucleoside reverse transcriptase inhibitors (NNRTI):
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