63 VHF

We’re trying to move away from referring to things as VHF as haemorrhage is not the most common feature seen with these.

63.1 VHF in Travellers

How do you assess for VHF in travellers?

  • You need visit to endemic country/outbreak country
    • Have you been to a rural area to actually increase your risk
    • Within 21 days
    • Compatible Syndrome

But FIRST EXCLUDE MALARIA!

ADD PHILS SLIDE ON THE PROBABILITY OF LASSA SURVIVAL

63.2 Clinical Features

  • Fever
  • Bleeding Tendency
  • Shock
  • Rash
  • Myalgia
  • GI Symptoms

What causes this stuff varies from disease to disease. But endothelial dysfunction and DIC/Bone Marrow suppression is common to all.

63.3 Marburg

First seen in Marburg in Germany, imported from South Africa.

Its same virus mortality rate. Around 80%

Thought to have fruitbat as a resevoir.

Possibility for transmission across central africa

One week incubation (up to 3 weeks)

Abrupt fever chills malaise. GI symptoms predominate. Profound watery diarrhoea that can kill from dehydration.

Haemorrhage is rare until preterminal.

63.3.1 Pathophysiology

Lot of ebola overlap. Enters skin via contact, all body fluids are infectious. So infectious via mucous membranes. Not aerosolised

Replicates in macrophage and dendritic cells. Blocks interferon production.

63.3.2 Diagnosis and Treatment

Acute Phase can have a v low WCC like seen in viral infections. As severe, WCC rises from endothelial dysfunction.

Diagnosis to PCR and ELISA

No specific treatment

Infection control is key

63.4 Lassa

Arenavirus

West Africa

Up to 80% asymptomatic. But amongst those who are admitted to hospital, mortality is high, 40%

The asymptomatic people are not infectious, but their fluids may be, but with way way lower risk.

One week to three week incubation

Non specific febrile illness.

Survivors commonly have sensorineural deafness following.

Semen can contain infective virus for up to 3 months after infection.

63.4.1 Prophylaxis?

Only for those with needle stick style injuries. Ribavirin

63.5 Crimean Congo Haemorrhagic Fever

FEVER AND TICK BITES, LOW WCC, LOW PLATELETS, RASH

Bunyavirus, transmitted via ticks.

Got animal resevoirs, Particularly in cattle, goats, sheep.

Made more spreadable via blood

More bleeding seen than others.

Less african but still v possible, more middle eastern and eastern european.

Farmer Tick Bites (Don’t squash ticks between your fingers) Those working in abatoirs Caring for affected people

63.6 Ribavirin

Ribavirin for VHF? Not effective for filo or flavi viruses

Reduces mortality in Lassa

Maybe maybe works in CCHF

63.7 Case 4

  1. What tests for cryptococcal meningitis:
  • Cryptococcal antigen test
  • Latex agglutination test
  • India Ink Staining
  1. How should they be treated?

We know that combination therapy is better.

If no monitoring available for amphotericin B, then do a week rather than 2 weeks of treatment (well you give longer for the fluconazole). All the side effects (renal) start to occur in the second week, so you’re going for less benefit but also less risk. Lots of places cannot get reliable potassium and fast potassium.

Monitoring you want is: Creatinine, Potassium, Haemoglobin

  • Amphotericin B
  • Fluconazole
  • Fluciasine
  • Therapeutic LP (you might need to drain 20-25 ml daily!)

If you don’t have a manometer use a giving set and a metre ruler.

  1. What about a counsellor not doing HIV testing?

Well a counsellor is only allowed to do an HIV test when a patient consents for it. You can explain it’s for medical reasons, and it should be done, but they can’t decide that on their own.

63.7.1 Cryptococcoma

Cryptococcocma of the skin is a large umbilicated lesion. It’s like a massive molluscum that looks more angry. The other thing that looks a bit like cryptococcoma, would be histoplasmosis.

63.8 Case 13

  1. What causes of epilepsy in this HIV positive patient?
  • Toxoplasmosis
  • Tuberculoma
  • Lymphoma (in a resource poor setting, they are just going to die anyway)
  • Cryptococcoma
  • Neurocystericosis (not more common in HIV, but v common in adult onset seizures)

Remembr that CD4 is key in distinguishing difference between the illnesses.

  1. What diagnostic tests?
  • LP w/ CRAG

Highest chance is that this is toxoplasmosis. You can treat empirically for toxo, and then if they don’t get better, then consider CT after.

  1. What anticonvulsants can be used in this setting?

Phenytoin and phenobarbitone are most common anticonvulsants. They interact horribly with ART’s though. Sodium valproate is a bit less available (but kind of available), but doesn’t interact with ARTs.

63.9 Case 8

3 Diff Dx for respiratory HIV infection, tachypnoeac, febrile, tachycardic, hypoxic:

  1. PCP
  2. Bacterial Pneumonia
  3. TB

Different timescale for those 3:

  1. Bacteral Pneumonia - Hours-Days
  2. PCP - Days-Weeks
  3. TB - Weeks-Months

Steroids for PCP? PO2 < 8. You never get ABG really, so use guidelines of respiratory distress and looks sick as whether to give steroids or not.

CD4 count for PCP? Less than 200

63.10 Case 25

Most common causes of diarrhoea in HIV patients? GET THE SLIDES LIST, BUT IN ORDER OF FREQUENCY

  • Drug Induced - Protease Inhibitors
  • CMV
  • Cryptosporidium
  • Cyclospora
  • Giardia
  • Salmonella
  • Shigella
  • TB Colitis
  • Kaposis Sarcoma

Diagnose and treating cryptosporidium

  • Stool Microscopy (Modified ZN)
  • Stool Culture

Treatment of patient with diarrhoeal illness in HIV:

  • Rehydration
  • Loperamide (you do need to do this for the HIV diarrhoea patients)
  • ART!
  • Empiric Ciprofloxacin and Metronidazole first
  • Then try bactrim if no success
  • THen albendazole if no success
  • Then MAC suspected (fever, lymphadenopathy, diarrhoea) = empiric azithromycin plus ethambutol

63.11 Case 7

DDx for HIV Associated Kaposis Sarcoma

  • Bacillary Angiomatosis (super super rare)
  • But in reality, not really any ddx, KS looking stuff is generally KS

How do you confirm a KS diagnosis?

  • Look for lesions in the mouth - if they’re there, super certain this is
  • Treat and see if it gets better?
  • Punch Skin Biopsy?

Number of lesions plus systemic involvement helps determine what to give treatment wise

Treatment is start on ART! +/- chemo (ADD SLIDE DETAILS ON WHAT TO GIVE)

63.12 Case 15

Most common areas affected by herpes zoster:

  1. Thorax
  2. Trigeminal Nerve Distribution

Three complications of herpes zoster:

  1. Bacterial Superinfection
  2. Eye Involvement
  3. Post herpetic neuralgia
  4. Cosmetically Scarring - And with the big association with HIV, think stigma of the scar

When do you consider IV drugs for Shingles?

  • When there’s (concerns about) eye involvement

63.13 Case 57

What other infectious causes can look like HIV Cardiomyopathy?

  • Pericardial/Pleural TB

Treated HIV Associated Cardiomyopathy

  • Diuretics
  • ACE
  • ?Digoxin
  • ?B Blockers

If you have peri/post partum cardiomyopathy, what is your prognosis?

  • More likely than not you will get better and back to normal EF
  • More likely than not you would get it again in a second pregnancy

If you have HIV associated dilated cardiomyopathy, what is your prognosis?

  • ARTs will stabilise things, will not improve things though.

63.14 Case 36

ADD THE FIVE MOST COMMON CAUSES OF ULCERATIVE STIS FROM REVISION WEEK

63.15 Case 6

Q: How do you calculate creatinine A: ?Cockroff - Gauld (definitely spelt wrong)

Q: Which ART is a worry about nephrotoxicity? A: Tenofovir

Tenofovir causes a fanconi-like syndrome []

HIV Associated Nephropathy - is an FSGS picture. Starting ARTs improve glomerular

ART Associated Nephrotoxicity - acts on the collecting duct

Fanconi - collecting duct tubular cells. No longer reabsorption of glucose, phostphate, amino acids, bicarbonate, sodium. Low phosphate, acidosis, glucosuria, hypokalaemia, proteinuria = FANCONI SYNDROME

Q: Hypokalaaemia, Hypophosphateamia, Acidosis, Glycosuria = What? A: Fanconi Syndrome

63.16 Case 10

How do you start Neveirapine? 2 weeks of low dose, thereafter standard dose?

Why do you have to slowly introduce neverapine? It’s hepatotoxic

Q: DDx of Deranged LFTs after starting ART: A: DILI, Super infection. IRIS / HBV flare

Q: Who’s more at risk of nevirapine hepatotoxicity? A: Women, Higher CD4 counts (250 women, 400 men)

63.17 Case 61

Q: What ARTs often cause gynaecomastia? A: Efavirenz (but loads of others also do)

63.18 Case 49

Q: What do you do with a case of Stevens-Johnson Syndrome on patient on prophylactic septrin and ARTs A: Stop everything! Gradually reintroduce

63.19 Case 51

Q: What’s the formal name for the pregnancy dipstick style tests (seen in CrAg) A: Lateral Flow Assay

Q: Positive cryptococcaemia, but not cryptococcal meningitis? A: Treat less hardcore than meningitic. Treat with fluconazole only (still a treatment dose. 800mg 4 weeks, 400 for following 4 weeks)

63.20 Case 55

When failing TDF/3TC/EFV, switch to AZT/3TC/Protease Inhibitor