AIDS – Acquired Immune Deficiency Syndrome

1. AIDS – Acquired Immune Deficiency Syndrome • A syndrome of opportunistic infections that occur as the final stage of infection by the human immunodeficiency virus (HIV) • Destruction & progressive loss of the immune function • Can affect any organ • First identified in 1981

2. AIDS Spectrum • Infected individuals that appear healthy • No signs of infection • Chronic Illness • Terminal Stage Disease

3. AIDS Spectrum • From the time of infection until full blown AIDS can take 1 year to 15 years • May take 6 weeks to a year from time of infection to when a person becomes HIV positive • May pass it on to others • False sense of security

4. Transmission of AIDS • Transmitted through body fluids • Tears • Saliva • Blood • Sexual Intercourse • Mother’s Breast Milk • Homosexuals, IV drug users/infected needles • Sex with multiple partners • Blood transfusions • Organ transplants

5. Protection Against AIDS • UNIVERSAL/STANDARD PRECAUTIONS!! • Gown, Gloves, Goggles • Protection from needle sticks • Never recap needles

6. Opportunistic Infections • Skin lesions • Purplish blotches or bumps on the face & extremities • Pneumonias • Bacterial (H Influenza & Streptococcus) • Viral Infections • Cytomegalovirus most common virus • Effects the lungs and eyes

7. Opportunistic Infections • Kaposi’s Sarcoma • Cancer of skin spreading to other sites (lungs & GI) • Tuberculosis • Fungal Infections • Mucosal & tongue Candidiasis • Fungal Pneumonias (Pneumocystis Carinii) • Eye infections • Cervical Cancers

8. Treatment • Supportive Care • Oxygen • Psychological counseling • Anti-viral agents • AZT • Retrovir • Videx • Treat individual infections

9. Treatment • Pneumocystis Carinii Pneumonia • IV or aerosolized pentamidine • Trade Name: Nebupent • Aerosolized pentamidine associated with less side effects. • Administered is given with Respirgard II nebulizer • Series of 3 one-way valves • Expiratory filter to trap exhaled particles • Particle size needs to be 1-2 microns to deposit in the alveoli

11. Dosage of pentamidine • Comes in a dry powder • 300 mg vial must be reconstituted with 6 mL of sterile water. • The entire 6 mL is placed in the nebulizer. • Give a bronchodilator before giving the pentamidine. • Given on out-patient basis; 300 mg/once a month.

12. Environmental Exposure to Healthcare Worker • Risk to Healthcare Workers (HCW) • Exposure to the drug. • Risk of infection with TB often associated with AIDS (airborne transmission). • HCW should be tested periodically for TB. • Nursing and Pregnant women should avoid exposure to the drug.

13. Environmental Risk of HCW • HCW have developed • Bronchospasm • Conjunctivitis • Need to protect themselves during administration • Gloves, mask and goggles • Stop nebulization if the patient takes the mouthpiece out of their mouth or if they stop to cough.. • Use an isolation booth or hood assembly with an exhaust fan and high efficiency filter.

14. Lung Abscess • Lung abscess is a necrotizing infection characterized by localized pus • Aspiration of oral and GI fluids containing anaerobic organisms. • Aspiration a result of impaired cough function (unconscious or obtunded from alcohol) • Mouth (between teeth and gums); poor oral hygiene: • Peptostreptococcus sp. • Bacteroides sp. • Fusobacterium sp. • Clostridium sp.

16. Chest Assessment • Increased tactile and vocal fremitus • Dull percussion note • Crackles/rhonchi • Pleural friction rub • Bronchial breath sounds • Whispered Pectoriloquy • Bronchophony or Egophony

17. Clinical Assessment • Nonproductive, barking or hacking cough. • Later, cough becomes productive. • Hemoptysis • Purulent • Painful respirations. • Pleural is involved. • Fever & sweats • Weight loss • Periodontal disease

18. Chest X-ray • Consolidation with single cavity containing an air-fluid level. • Air bronchograms • Pleural effusions • Silhouette sign

19. Aspiration Pneumonitis • Aspiration of gastric juice with a pH of 2.5 or less causes serious and fatal pneumonia • Acute inflammatory reaction does not usually occur until 12-24 hours after aspiration • Can lead to the development of ARDS • Mendelson’s Syndrome

20. Lipoid Pneumonitis • Aspiration of oil • Mineral Oils • Oils from animal fat

21. Avian Flu

22. Influenza Pandemic • Pandemic vs. Epidemic • Three conditions must be met for an Influenza pandemic to start: • A new influenza virus subtype must emerge for which there is little or no human immunity; • It must infect humans and causes illness; and • It must spread easily and sustainably (continue without interruption) among humans.

23. Past Influenza Pandemics • 1933: Influenza virus first isolated • 1918-1920: Spanish Flu (H1N1) • Hundreds of millions infected; 50 million deaths (600,000 in US) • Mortality highest in 20- to 40-year age group • 1957: Asian Flu (H2N2) • Million deaths worldwide (80,000 in US) • 1968: Hong Kong Flu (H2N2) • 700,000 deaths (34,000 in US)

24. Avian Flu • H5N1 virus • Thought to have originated by reassortment between multiple cocirculating avian influenza strains prevalent in Hong Kong in 1997. • Continued evolution since 1997. • Human transmission appears to be associated with close contact with infected poultry. • Plucking • Playing • Cock fights • Drinking raw duck blood

25. Human-to-Human Transmission • Rare • 15 family clusters involving more than two family members documented between 1/04 & 7/05. • 200 cases worldwide – none in US. • 2006: H5N1 found in Azerbaijan, Cambodia, China, Djibouti, Egypt, Indonesia, Iraq, Thailand, Turkey • http://www.cdc.gov/flu/avian/

26. Symptoms of Avian Flu • Non-specific complaints of fever. • Cough • Dyspnea • Conjunctivitis • CXR: Diffuse infiltrates; rare pleural effusions. • Lab: Leukopenia

27. Treatment for Avian Flu • Supportive • Antiviral drugs • amantadine, rimantadine, oseltamivir, and zanamivir • Vaccine • Flu vaccine not effective

28. Swine Flu http://www.cdc.gov/h1n1flu/key_facts.htm

29. Severe Acute Respiratory Syndrome (SARS)

30. SARS Outbreak • Emerged from Southern China • First case reported 11/16/02 • 1/31/03 patient presented to hospital in Guangdong, China. • Transmission to 49 HCWs and 19 family members. • Spread throughout local municipalities. • Carried to Hong Kong by nephrologist attending a wedding. • Transmission to 15 hotel guests (including international travelers) • Outbreaks in Vietnam, Canada, Singapore, & Phillipines

31. Coronovirus • Novel human coronovirus (SARS-CoV) • Coronaviruses are enveloped RNA viruses. • Some strains well-recognized as causing the common cold. • Transmission to human thought to be associated with the handling (and eating) of the palm civet, ferret badgers, and raccoon dogs.

32. Epidemiology & Clinical Presentation • Transmission is by inhalation of infected respiratory droplets • Incubation period is 2 to 10 days • Maximum infectivity does not occur at the time of symptom onset (unlike most viruses) • Occurs in 2nd week and at the time of rapid clinical deterioration. • Initial symptoms resemble influenza, with fever, cough, chills, rigor, and myalgia.

33. Diagnostic Testing • CXR: Usually normal initially • Pulmonary infiltrates as disease progresses • Lab: WBC normal or low

34. Treatment • Supportive • 70-80% have full recovery • Others develop ARDS-like picture and 50% die • Mechanical Ventilation • Anti-Viral Agents • oseltamivir • ribavirin • ISOLATION! • Protection of healthcare workers. • N-95 masks