HIV Case I - meduploader

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A 23-year-old male presents to the urgent care clinic
complaining of sore throat, fever, and body aches. He
reports that the illness began about 1 week ago and
has persisted despite therapy with NSAIDs, acetaminophen,
and sore throat lozenges. He has not
sought medical advice for this condition previously.
He denies cough, abdominal pain, nausea, or vomiting,
but reports a persistent headache. His past medical
and surgical history is unremarkable. The patient
smokes about 1 pack of cigarettes a week, drinks occasional
alcohol, and denies other drugs, including
intravenous use. He is heterosexual, and has had 3 sexual
contacts in the past year.
On exam his vital signs are: T 38.9° C; P 112;
BP 115/68; R 20. General: well-nourished male who
appears uncomfortable. Head, ears, eyes, and nose are
unremarkable. The patient has pharyngitis and enlarged
tonsils with exudates. There is diffuse cervical
lymphadenopathy, but the neck is supple. There are
enlarged nodes in his axilla and inguinal areas as well.
The spleen is palpable and nontender. The rest of the
exam is unremarkable.
In addition to a throat culture, blood count, and
Mono Spot, an appropriate laboratory test to
rule out the acute retroviral syndrome would be:
A) HIV-1 antibody by ELISA and Western blot.
B) HIV-1 antibody by rapid detection method.
C) HIV-1 p24 antigen or HIV viral load by PCR.
D) CD4 T lymphocyte count.
E) Sperm centrifuge for viral culture.

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q2.
After appropriate treatment and adequate counseling,
follow-up is arranged for this patient. He returns to
the office 2 months later with no complaints or symptoms.
A complete history and physical are performed.
The patient has mild cervical lymphadenopathy and
no other findings. Laboratory studies are ordered and
show:
WBC 3,200 cells/mm3
Chemistry panel (normal)
Anti-HIV ab (+)
Hct 42%
Liver enzymes (normal)
Platelets 185,000 cells/mm3
CD4 lymphocytes 645 cells/mm3
HIV viral load 5,000 copies/ml

What other baseline studies should now
be ordered?
A) PPD.
B) RPR.
C) Toxoplasma antibody.
D) Hepatitis B and C antibody.
E) All of the above.

Q3.
The patient is counseled appropriately about all the
results.
What is the most important factor in
determining when to start highly active
antiretroviral therapy (HAART)?
A) A rising viral load.
B) A decrease in CD4 count.
C) The development of an opportunistic infection.
D) The patient™s willingness and ability to comply
with the difficult regimens involved.
E) An undetectable viral load (200 cells/mm3.
C) No, because he has only been diagnosed with HIV
infection for 1 year.
D) Yes, because he has had recurrent (>2 episodes) of
lobar pneumonia.
E) Yes, because his viral load is >100,000 copies/ml.

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First question answer is ©

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Question 2.(E)

Question 3.©

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1. C
2. E
3. B

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Q4
Aside from considering HAART and
stressing the importance of partner notification,
what other treatment should be offered at
this stage?
A) Oral polio vaccine.
B) Pneumococcal and hepatitis B vaccines.
C) Trimethoprim/sulfamethoxazole (TMP/SMX)
DS 1 tab/day for the prevention of Pneumocystis
carnii.
D) Azithromycin 1,250 mg per week for the prevention
of Mycobacterium avium complex (MAC).
E) Fluconazole 100 mg per day for the prevention of
cryptococcal meningitis.

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Q5
The patient elects not to start therapy at this time and
is scheduled for follow-up with regular checks of his
viral load and CD4 count. After 1 year, the patient™s
lab values have changed: CD4 lymphocytes 220; viral
load 110,000 copies/ml. In the past year, he has been
treated 3 times for lobar pneumonia, and for oral candidiasis
(but no esophageal disease).
Does this patient meet the CDC case
definition for the acquired immune deficiency
syndrome (AIDS)?
A) No, because he has not had an AIDS-defining
illness.
B) No, because his CD4 count is >200 cells/mm3.
C) No, because he has only been diagnosed with HIV
infection for 1 year.
D) Yes, because he has had recurrent (>2 episodes) of
lobar pneumonia.
E) Yes, because his viral load is >100,000 copies/ml.

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Q6
The patient agrees that this would now be a good time
to start therapy with HAART and is ready to adhere
to the regimen.
In order to maximize compliance, which of
the following combinations of drugs should
be recommended?
A) Indinavir TID plus Combivir BID.
B) Nelfinavir BID plus Combivir BID.
C) Ritonavir BID plus saquinavir BID plus zidovudine
BID.
D) Ritonavir BID plus saquinavir BID plus lamivudine
BID.
E) Ritonavir BID plus saquinavir BID plus didanosine
QHS.

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Q7.
The patient is started on nelfinavir plus Combivir. He
does well with the treatment, and tolerates the medications.
On a later routine follow-up, he reports mild
fatigue, but is otherwise well. His lab results over several
visits are shown in Table 9-1. Current labs also
include: WBC 4,500 cells/mm3, Plts 128,000 cells/
mm3, Hb 10.1 g/dl, MCV 110 fL, Hct 29.8%.
At this point, what changes, if any, should be
made to the patient™s regimen?
A) The patient has failed HAART treatment, and the
drug regimen should be changed.

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B) The patient has suffered a severe adverse effect
(anemia) from the drug regimen and all 3 drugs
should be changed.
C) The patient is doing well, but needs B12 and folate
supplementation due to his macrocytic anemia.
D) The patient has failed to reconstitute his immune
system (CD4 count still 200 cells/mm3), so one
of his drugs should be changed.
E) The patient is doing well and his regimen should
be continued. The macrocytic anemia is an expected
and manageable side effect from the zidovudine
component of the Combivir.