WBR0307

Author	[[PageAuthor::Mugilan Poongkunran M.B.B.S [1]]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Primary Care Office
Sub Category	SubCategory::Infectious Disease, SubCategory::Respiratory
Prompt	[[Prompt::A 40 year old male come to clinic for a follow up visit regarding his HIV status. He was diagnosed with HIV 1 year back and has been taking zidovudine, lamivudine and indinavir since then. He currently has no symptoms and has been compliant with his medications. At the first visit his CD4 count was 50, and you started him on trimethoprim-suphamethoxazole, ganciclovir, fluconazole and azithromycin. His CD4 counts taken every four months were 75 and 100 respectively. His vitals are pulse 80/min, BP: 120/80 mmHg, temperature 100 F, RR: 15/min. Chest auscultation was unremarkable and heart sounds are normal. His abdomen is soft and non tender. No generalized lymphadenopathy. CD4 count taken 1 week back is 25O, seronegative for CMV and his CBC, serum biochemistry, urine analysis and LFT’s are all within normal limits. What is the most appropriate line of management in this patient?]]
Answer A	AnswerA::Continue HAART, TMP-SMX, ganciclovir, fluconazole and azithromycin
Answer A Explanation	[[AnswerAExp::Incorrect : With CD 4 count more than 100 cells/µL for more than 3 months without any symptoms, we can safely discontinue prophylaxis for MAC, CMV and cryptococcus.]]
Answer B	AnswerB::Continue HAART, TMP-SMX
Answer B Explanation	[[AnswerBExp::Correct : With CD 4 count more than 100 cells/µL for more than 3 months without any symptoms, we can safely discontinue prophylaxis for toxoplasmosis and pnuemocystitis infection. However this patient just reached a CD4 count of 250 cells/µL and it would wise to continue his prophylaxis for toxoplasmosis and pnuemocystitis for another 3 months.]]
Answer C	AnswerC::Continue HAART, TMP-SMX, azithromycin
Answer C Explanation	AnswerCExp::'''Incorrect''' : With CD 4 count more than 100 cells/µL for more than 3 months without any symptoms, we can safely discontinue prophylaxis for MAC i.e azithromycin.
Answer D	AnswerD::Continue HAART, TMP-SMX, fluconazole
Answer D Explanation	[[AnswerDExp::Incorrect : We recommend that antifungal prophylaxis (fluconazole) NOT be used routinely to prevent cryptococcosis because of the relative infrequency of cryptococcal disease. However, even if you start, it is not required to continue after CD4 is 100 cells/µL.]]
Answer E	AnswerE::Continue HAART
Answer E Explanation	[[AnswerEExp::Incorrect : We recommend discontinuation of primary prophylaxis (trimethoprim-suphamethoxazole) for pneumocystis and toxoplasmosis when the CD4 count is >200 cells/microL for three months.]]
Right Answer	RightAnswer::B
Explanation	[[Explanation::HIV-related immunosuppression significantly increases the risk for acquiring opportunistic infections due to bacteria, viruses, fungi, and protozoa. These opportunistic infections are a major source of morbidity and mortality in HIV-infected patients. Patients with a CD4 count <50 cells/microL are at risk for pneumocystis carnii, toxoplasmosis, CMV, cryptococcal and MAC infections. Patients with a CD4 count <100 cells/microL are at risk for developing Pneumocystis and toxoplasmosis infection. Patients with a CD4 count <200 cells/microL are at risk for developing pneumocystis infection. Treatment guidelines are that we recommend discontinuation of primary prophylaxis (azithromycin or clarithromycin) for mycobacterium avium complex when the CD4 count is >100 cells/microL for three months. We recommend discontinuation of primary prophylaxis (trimethoprim-suphamethoxazole) for pneumocystis and toxoplasmosis when the CD4 count is >200 cells/microL for three months. Risk of CMV disease occurs mainly due to reactivation of latent infection especially when CD4 counts are less than 50 cells/microL. However, we do NOT suggest routine prophylaxis due to cost, risk of resistance, and lack of proven survival benefit. We recommend that antifungal prophylaxis NOT be used routinely to prevent cryptococcosis because of the relative infrequency of cryptococcal disease, lack of survival benefits associated with prophylaxis, possibility of drug interactions, potential antifungal drug resistance, and cost. Educational Objective: References: ]]
Approved	Approved::Yes
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