Bored with my CD4

Let’s talk about the patient with HIV, who maybe presents with a fever, and says he doesn’t know his last CD4 count but thinks it’s ‘not good.’

Reach back into that fund of knowledge you’ve perhaps suppressed from your crazy, cramming, coffee-chugging days of Step 1 & 2, and tell me what opportunistic infections you’re concerned for at each CD4 count and the prophylaxis & treatment. Alternatively, if the patient says he’s on a certain prophylactic medication, you can assume/deduct his CD4 count…

CD4 > 200

Tuberculosis– treatment: “RIPE” rifampin, isoniazid, pyrazinamide, ethambutol

Bacterial pneumonia – most common pulmonary infection in HIV patients, usually Strep. pneumo

Candidiasis / thrush– nystatin or clotrimazole. Esophagitis- Fluconazole.

CD4 < 200

PCP… (or P. jiroveci for you modernists). Especially consider this diagnosis if the patient has hypoxia without another explanation.

Treatment: TMP-SMX 2 DS tabs TID x 2 weeks. If PaO2 < 70 or A-a gradient > 35, add prednisone.

Prophylaxis: for all patients with CD4 < 200 is TMP-SMX 1DS tab daily.

Histoplasmosis- Treatment: Amphoteracin B and itraconazole. No prophylaxis.

CD4 < 100

Toxoplasmosis! (my favorite, being a cat-lady and all…) Treatment: prymethamine, sulfadiazone, and folinic acid. Prophylaxis: TMP-SMX 1DS tab daily.

Cryptosporidium (diarrhea)- No effective cure! Can only help by treating with HAART.

Cryptococcus (meningitis)- Treatment is amphotericin B and flucytosin. Prophylaxis: debatable, but if there is detectable antigen in an endemic region they can be started on fluconazole.

CMV (retinitis)- Treatment: ganciclovir or foscarnet. Prophylaxis: ganciclovir

CD4 < 50

Disseminated MAC. Treatment: clarithromycin, ethambutol, rifabutin. Prophylaxis: azithromycin or clarithromycin.

References

Pic: http://www.thebody.com/content/art13706.html

Tintinalli’s 7th ed. Ch 149.

Uptodate.com

Special Thanks to Dr. Willis