DESCRIPTION

• AIDS: Defined as lab evidence of HIV with CD4 < 200 or AIDS defining illness—infection (e.g., cryptosporidium), malignancy (e.g., Kaposi, cervical cancer), or other (e.g., HIV wasting disease, HIV encephalopathy)
• Opportunistic diseases:
  • CD < 500 cells/mm³:
    • Oroesophageal candidiasis
    • Pneumococcal infection
    • Hairy leukoplakia
    • Immune thrombocytopenic purpura
  • CD4 < 200 cells/mm³:
    • Pneumocystis jiroveci pneumonia (PCP)
    • Cryptococcal infection
    • Disseminated tuberculosis
    • Cryptosporidiosis
    • Isosporiasis
    • Toxoplasmosis
    • Histoplasmosis
  • CD4 < 50 cells/mm³:
    • CNS lymphoma
    • Mycobacterium avium complex (MAC)
    • TB pericarditis or meningitis
    • Cytomegalovirus (CMV)
    • Cholangiopathy: Most common cause Cryptosporidium parvum

SIGNS AND SYMPTOMS

• Primary HIV infection: 2–6 wk after exposure:
  • Fever and malaise
  • Rash on face and trunk
  • Flu-like syndrome with lymphadenopathy and hepatosplenomegaly
  • Pharyngitis
  • Diarrhea
  • Up to 90% asymptomatic
• Advanced HIV disease (CD4 < 200):
  • Fatigue
  • Fevers and night sweats
  • Weight loss/wasting
  • Alopecia
  • Chronic diarrhea
  • Cough
  • Dyspnea
  • Hemoptysis
  • Chronic low-grade headache
  • Altered mental status
  • Seizures
  • Dementia
  • Neuropathy
  • Painless visual loss
  • Skin lesions

History

• Risk factors:
  • Sexual promiscuity, multiple sexual partners
  • IV drug abuse
  • Men who have sex with men
  • Blood transfusions prior to 1985
  • Unprotected sex with at-risk partners
  • Uncircumcised
• Most recent CD4 count and viral load, lowest CD4 count
• History of or current use of antiretroviral medications
• Medication compliance
• Length of diagnosis/illness
• History of opportunistic infections
• Previous hospitalizations or ICU admissions

ESSENTIAL WORKUP

• HIV serologic tests as noted below:
  • There is a window of 24 wk between primary infection and seroconversion, during which tests may be negative.
  • DNA amplification testing can be positive within 1–2wks of infection, although may not be practical to perform from ED and requires close follow-up and counseling.
• Respiratory symptoms:
  • Chest radiograph
  • Arterial blood gas (ABG)
  • Sputum for Gram stain, AFB, and culture
  • Serum LDH—elevated in PCP
  • Blood cultures
• Cardiac symptoms:
  • Serum cardiac markers, electrolytes
  • CXR
  • ECG in cases of suspected pericarditis, effusion, or tamponade
  • Blood cultures if endocarditis is suspected
  • Drug screen for cocaine and amphetamines
• Neurologic symptoms:
  • Head CT with and without contrast
  • Lumbar puncture with opening pressure
  • CSF for glucose, protein, Gram stain and culture, cell count with differential, AFB smear, India ink stain, herpes simplex and cryptococcus antigen, and VDRL
• GI symptoms:
  • Stool for ova and parasites, Gram stain, culture, and Clostridium difficile assay
  • Urine analysis
  • For women: Urine pregnancy test, pelvic exam with wet mount, and gonorrhea/chlamydia testing
  • Liver functions tests, amylase, and lipase
  • Hepatitis serologies
  • Low threshold for CT abdomen/pelvis
  • US if biliary symptoms present
  • Low threshold for surgical consult, as HIV patients may not present with classic acute abdomen
• Fever workup:
  • Include aerobic/anaerobic, fungal, AFB, and MAC blood cultures
• Ocular symptoms:
  • Fluorescein staining with slit lamp exam

DIAGNOSIS TESTS & INTERPRETATION

Lab

• ELISA:
  • Detects IgG antibody against HIV
  • Sensitivity and specificity ~99%
  • Can be negative during the window period
• Western blot:
  • Detects IgG antibody against HIV proteins p24, gp 120, gp 41
  • Used to confirm a positive ELISA
  • Able to detect HIV during the 6 mo seroconversion period
• Rapid HIV testing:
  • Results available in 5–20 min
  • 4 types of tests currently available
  • Samples include oral swabs, whole blood, serum, or plasma
  • All reactive tests require confirmatory testing with western blot or ELISA
  • > 99% specific and sensitive
• Absolute lymphocyte count (ALC):
  • Multiply WBC × percent lymphocytes
  • If ALC > 2,000, likely CD4 > 200, if ALC < 1,000, likely CD4 < 200

Imaging

• CXR:
  • Bilateral interstitial infiltrates: PCP
  • Reticulonodular infiltrates: TB, KS, or fungal pneumonia
  • Hilar lymphadenopathy with infiltrate: TB, cryptococcosis, histoplasmosis, neoplasm
  • Lobar consolidation: Bacterial pneumonia
  • Cavitation: TB, necrotizing bacterial pneumonia, coccidioidomycosis
  • Normal x-ray does not rule out PCP or TB
• Head CT with and without IV contrast:
  • Multiple ring-enhancing lesions with edema in basal ganglia or cortex: Toxoplasmosis or CNS lymphoma
  • Subcortical nonenhancing lesions: PML
• Abdominal/pelvic CT:
  • Splenomegaly: CMV, TB
  • Intestinal perforation or bowel obstruction: CMV colitis, lymphoma, histoplasmosis, MAC, appendicitis, ulcer disease, KS
  • Cholecystitis or cholangitis: Cryptosporidium, Microsporidium, CMV
  • Pancreatitis: Medication-related, neoplasm, infectious

DIFFERENTIAL DIAGNOSIS

• For pulmonary symptoms with HIV:
  • Pulmonary emboli
  • Pulmonary HTN
  • TB
  • Pneumonia: Bacterial, fungal, viral
  • Pulmonary malignancies
  • Lymphocytic interstitial pneumonitis
• For CNS symptoms with HIV:
  • Neurosyphilis
  • CMV or HSV encephalitis
  • Toxoplasmosis
  • CNS lymphoma
  • Meningitis (bacterial, coccidioidal, etc.)
  • Subarachnoid hemorrhage
  • Cerebral infarction
  • HIV or metabolic encephalitis
  • Progressive multifocal leukoencephalopathy
• Cardiac symptoms with HIV:
  • Cardiomyopathy
  • Pericarditis/myocarditis
  • Endocarditis
  • Acute coronary syndrome
  • Pericardial effusion
• Oral symptoms with HIV:
  • Fungal infection (i.e., candidiasis)
  • Viral lesions (HSV, CMV, hairy leukoplakia)
  • Bacterial lesions (TB, periodontal disease)
  • Autoimmune (salivary gland disease, aphthous ulcers)
  • Neoplasm (KS, lymphoma)
• Esophageal symptoms with HIV:
  • Infectious esophagitis (candida, CMV, HSV)
  • Reflux esophagitis
• Diarrhea with HIV:
  • Medication side effect
  • Parasites (Cryptosporidium, Giardia, Isospora)
  • Bacteria
  • Viral (CMV, HSV, HIV)
  • Fungi (histoplasmosis, cryptococcus)
  • HIV-associated enteropathy
• Hepatomegaly with HIV:
  • Hepatitis
  • Opportunistic infection (CMV, MAC, TB)
• Renal disease with HIV:
  • Drug nephrotoxicity
  • HIV nephropathy
  • Vasculitis
  • Obstruction

[Outline]

• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

ED TREATMENT/PROCEDURES

• Patients who appear to have bacterial infections, appear toxic, or have rapidly progressive symptoms should receive their 1st dose of antibiotics in the ED.
• Begin HIV treatment if: Low CD4 (< 350) or high viral load, pregnancy, AIDS defining illness or HIV-associated nephropathy (in general, patients with documented primary HIV infection also undergo resistance testing after the diagnosis has been established)
• Triple therapy (HAART):
  • 1 non-nucleoside reverse transcriptase inhibitors (NNRTI) and 2 nucleoside reverse transcriptase inhibitors (NRTI)
  • 1 PI and 2 NRTIs
  • Triple NRTI
• Postexposure prophylaxis:
  • Start therapy within 2 hr if possible and continue for 4 wk
  • 2-drug regimen for most exposures:
    • Zidovudine + lamivudine (combivir)
    • Lamivudine + stavudine
    • Stavudine + didanosine
  • 3-drug expanded regimen for very high-risk exposure
• Toxoplasmosis: Pyrimethamine:
  • Sulfadiazine
  • Leucovorin
  • Steroids for cerebral edema
  • Treat for at least 6 wk
• Cryptococcal meningitis:
  • Amphotericin B
  • Flucytosine
  • Treat with above for 2 wk, then fluconazole for 8 wk
• CMV retinitis: Ganciclovir
• Esophageal candidiasis:
  • Fluconazole for 14–21 days
• MAC: Clarithromycin:
  • Ethambutol
  • May add rifabutin if severe immunosuppression
• PCP:
  • Trimethoprim/sulfamethoxazole
  • Pentamidine or dapsone for sulfa-allergic patients
  • If PaO₂ < 70 mm Hg or A-a gradient > 35 mm Hg, add prednisone 40 mg PO BID for 5 days, then taper
• Oral candidiasis: Clotrimazole troches
• HIV acute demyelinating polyneuropathy: Plasmapheresis

MEDICATION

• Common medication complications:
  • Hypersensitivity reaction: Abacavir
  • Pancreatitis:
    • Dideoxyinosine
    • Dideoxycytidine
    • Didanosine
    • Lamivudine
    • Cotrimoxazole
    • Pentamidine
    • Ritonavir
    • Stavudine
    • Zalcitabine
  • Peripheral neuropathy:
    • Didanosine
    • Isoniazid
    • Linezolid
    • Stavudine
    • Zalcitabine
  • Kidney stones: Indinavir and Atazanavir
  • Hepatotoxicity: All agents to some degree:
    • Nevirapine
    • Didanosine
    • Stavudine
  • Lactic acidosis: Stavudine:
    • Didanosine
  • Stevens–Johnson syndrome:
    • Nevirapine
    • Atazanavir
    • Delavirdine
    • Efavirenz
    • Cotrimoxazole
    • Trimethoprim/sulfamethoxazole
  • Hemolytic anemia:
    • Dapsone (used for treatment of TB)
    • Zidovudine with ribavirin
  • Psychosis: Efavirenz
  • Hypoglycemia: Pentamidine
  • Postural hypotension: Maraviroc
  • Hyperlipidemia, truncal obesity, and atherosclerosis: Stavudine:
    • Protease inhibitors
  • Dilated cardiomyopathy: Zidovudine
  • Benign increase in unconjugated bilirubin: Atazanavir and indinavir
  • Macrocytic anemia: Zidovudine
  • Many cause some hematologic effects, GI upset, and rash

[Outline]

• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

• Unexplained fever with CNS involvement or suspected endocarditis
• Neutropenic fever
• Hypoxemia (PaO₂ < 70 mm Hg)
• Cardiac symptoms suggestive of ACS
• Pericardial effusion
• Suspected bacterial pneumonia or TB
• A change in neurologic status
• New-onset seizures
• Hemodynamic instability
• Inability to ambulate or tolerate oral intake
• Intractable diarrhea with dehydration

Discharge Criteria

The patient can maintain adequate oral intake, provide self-care, and ambulate.

Issues for Referral

• Patient should be referred to a primary HIV care provider for initiation of HAART therapy regimen and ongoing care.
• Be alert for signs of depression and refer for counseling or psychiatric treatment as this may inhibit treatment compliance.
• HIV patients are at higher risk for many malignancies—refer those with concerning symptoms for follow-up.

• Immune reconstitution inflammatory syndrome usually manifests within 8 wk of initiation of HAART as symptoms of opportunistic or autoimmune disease.
• For occupation exposures, there is a low risk of seroconversion (0.3% for significant percutaneous exposure and 0.09% for mucocutaneous).
• HIV patients on HAART should be considered at higher risk for insulin resistance and acute coronary syndrome/CAD, independent of other risk factors.
• Measure oxygen saturation after walking in patients with a normal CXR and symptoms of pneumonia to help diagnose PCP.
• HIV is an independent risk factor for COPD, pulmonary hypertension, CVA, venous thromboembolic disease, TTP, osteoporosis, and osteonecrosis of the hip.

ICD9

• 042 Human immunodeficiency virus [HIV] disease
• V08 Asymptomatic human immunodeficiency virus [HIV] infection status
• 007.4 Cryptosporidiosis

ICD10

• A07.2 Cryptosporidiosis
• B20 Human immunodeficiency virus [HIV] disease
• Z21 Asymptomatic human immunodeficiency virus infection status

[Outline]

• ICD9
• ICD10

• Belleza WG, Browne B. Pulmonary considerations in the immunocompromised patient. Emerg Med Clin North Am. 2003;21(2):499–531.
• Church JA. Pediatric HIV in the emergency department. Clin Ped Emerg Med. 2007;8:117–122.
• Marco CA, Rothman RE. HIV infection and complications in emergency medicine. Emerg Med Clin North Am. 2008;26:367–387.
• Self W. Acute HIV infection: Diagnosis and management in the emergency department. Emerg Med Clin North Am. 2010;(28):381–392.
• Venkat A, Piontkowsky DM, Cooney RR, et al. Care of the HIV-positive patient in the emergency department in the era of HAART. Ann Emerg Med. 2008;52:274–285.

Anika Backster

Murtaza Akhter