Clinical Cass 33 Pornpan Suksawadnumchok Sec C
Case 33 • Having been confined in the hospital for almost a month due to recurrent pneumonia, Mr. xxy, 42 y/o, married, a dance instructor in Japan for almost 10 years was diagnosed to have AIDS
Diagnosis • HIV infection almost 10 yerars lead to recerrent pneumonia
Lab diagnosis • enzymeimmunoassay • Western blot assay • Indirect fluorescent antibody assay (IFA) • Radioimmunoprecipitation assay (RIPA)
AIDS • Acquired Immune Deficiency Syndrome or acquired immunodeficiency syndrome (AIDS or Aids) is a collection of symptoms and infections resulting from the specific damage to the immune system caused by the human immunodeficiency virus (HIV) • HIV is a retrovirus that primarily infects vital components of the human immune system such as CD4+ T cells, macrophages and dendritic cells. • It directly and indirectly destroys CD4+ T cells. CD4+ T cells are required for the proper functioning of the immune system. • When HIV kills CD4+ T cells so that there are fewer than 200 CD4+ T cells per microliter (µL) of blood, cellular immunity is lost, leading to the condition known as AIDS. • The late stage of the condition leaves individuals prone to opportunistic infections and tumors
Transmission of HIV Direct contact • mucous membrane • bloodstream with a bodily fluid containing HIV • semen • vaginal fluid • preseminal fluid • breast milk • This transmission can come in the form of anal, vaginal or oralsex, blood transfusion, contaminated hypodermic needles, exchange between mother and baby during pregnancy, childbirth, or breastfeeding
Main HIV symptoms: • Rapid weight loss • Dry cough • Recurring fever • Wollen lymph glands in the armpits, groin, or neck • Diarrhea that lasts for more than a week • White spots on the tongue, in the mouth, or in the throat • Pneumonia • Red, brown, pink, or purplish blotches on or under the skin or inside the mouth, nose, or eyelids • Memory loss, depression, and neurological disorders
Major pulmonary illnesses • Pneumocystis carinii pneumonia (PCP) is caused by the ubiquitous unicellular eukaryote, P carinii. • It is a rare cause of infection in the general population, but it is a frequent cause of morbidity and mortality in persons who are immunocompromised, especially patients with acquired immunodeficiency syndrome (AIDS).
Treatment • The treatment of P carinii pneumonia is one of the first concerns in HIV treatment. • Nucleoside reverse transcriptase (RT) inhibitors - also called nucleoside analogs - Zidovudine (AZT) - also called ZDV - Zalcitibine (ddC) - Didanosine (ddI) - Stavudine (d4T) • Pneumonia - Clotrimazole - Clarithromycin - Azithromycin
Zidovudine (AZT) • Zidovudine (INN) or azidothymidine (AZT) (also called ZDV) is an antiretroviral drug, the first approved for treatment of HIV. Machanism of action • inhibiting the action of reverse transcriptase, the enzyme that HIV uses to make a DNA copy of its RNA.
Zidovudine (AZT) • Adult Dose: 200 mg PO tid 1-2 mg/kg/dose IV q4h • Pediatric Dose: 90-180 mg/m2/dose PO q6h 1-2 mg/kg/dose IV q4h • Contraindications: hypersensitivity • Interactions:Acetaminophen may decrease bioavailability; amphotericin B, flucytosine, vincristine, vinblastine, doxorubicin, cimetidine, indomethacin, lorazepam, aspirin, acyclovir, ganciclovir, dapsone, and pentamidine may increase toxicity • Precautions:Caution in impaired hepatic or renal function; reduce or stop therapy in hematologic disorders, such as thrombocytopenia, granulocytopenia, and severe anemia
Clotrimazole • Clotrimazole -- Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability. Pruritus usually relieved within first week of treatment.
Clotrimazole • Adult Dose:10 mg PO 5 times/d for 14 d Pediatric Dose:<3 years: Not established>3 years: Administer as in adults • Contraindications: hypersensitivity • InteractionsNone reported Pregnancy- Usually safe but benefits must outweigh the risks. • Precautions:Not for treatment of systemic fungal infections; avoid contact with eyes; if irritation or sensitivity develops, discontinue use and institute appropriate therapy
Clarithromycin • Clarithromycin (Biaxin) -- Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest. • Another initial DOC in otherwise uncomplicated pneumonia. Appears to cause more GI symptoms (eg, gastric upset, metallic taste) than azithromycin.
Clarithromycin • Adult Dose: 500 mg PO bid for 10 d • Pediatric: Dose<6 months: Not recommended>6 months: 7.5 mg/kg PO bid for 10 d; not to exceed 500 mg/dose • Contraindications: hypersensitivity; • coadministration of pimozide • Interactions: Toxicity increases with coadministration of fluconazole and pimozide; effects decrease and GI adverse effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, • Pregnancy: C - Safety for use during pregnancy
Azithromycin • Azithromycin (Zithromax) -- In otherwise uncomplicated pneumonia, initial DOC; covers most potential etiologic agents, including Mycoplasma species. Compared with other drugs, causes less GI upset; potential for good compliance because of reduced dosing frequency. Has better action against H influenzae compared with erythromycin. Main disadvantage is cost. • Adult Dose:Day 1: 500 mg PODays 2-5: 250 mg PO qdAlternative: 500 mg IV qd • Pediatric: DoseDay 1: 10 mg/kg PODays 2-5: 5 mg/kg PO qd
Azithromycin • Contraindications:Documented hypersensitivity; hepatic impairment; do not administer with pimozide • Interactions: May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine • Pregnanc: Usually safe but benefits must outweigh the risks. • Precautions: IV-site reactions can occur; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients