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1
Question:

A 42-year-old man comes to the office due to a skin rash on his left lower extremity.  A month ago, the patient noticed several purple spots on his left calf that have progressively enlarged but are not painful or pruritic.  He has no chronic medical conditions but has been treated for primary syphilis and anal gonorrhea.  Temperature is 37.2 C (98.9 F), blood pressure is 136/82 mm Hg, and pulse is 86/min.  Physical examination shows 3 purple-colored, elliptical papules measuring 1-2 cm on the left lateral calf.  HIV testing is positive, CD4 count is 45/mm3, and HIV viral load is 45,000 copies/mL.  In addition to antiretroviral therapy and treatment of the skin lesions, which of the following is recommended for this patient?

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Explanation:

Opportunistic infections in HIV

Infection

CD4 cell count

Prophylaxis

Pneumocystis jirovecii

  • <200/mm3 OR
  • Oropharyngeal candidiasis OR
  • History of PCP infection

Trimethoprim-sulfamethoxazole

Alternate therapies:

  • Dapsone
  • Atovaquone
  • Pentamidine

Toxoplasma gondii

<100/mm3 & positive IgG antibody

Trimethoprim-sulfamethoxazole

Alternate therapies:

  • Dapsone plus pyrimethamine plus leucovorin
  • Atovaquone ± pyrimethamine plus leucovorin

Histoplasma capsulatum

<150/mm3 & endemic area

Itraconazole

VZV

Close contact with person with chickenpox or shingles & no history of prior disease or negative antibody to VZV

VariZIG or IVIG administered within 4 days of exposure

IVIG = intravenous immune globulin; PCP = Pneumocystis jirovecii pneumonia; VariZIG = human varicella immune globulin; VZV = varicella-zoster virus.

This patient's purple, elliptical papules in the setting of a history of anal gonorrhea (indicating risk for HIV transmission) raises strong suspicion for the AIDS-defining malignancy, Kaposi sarcoma.  Patients with suspected HIV generally undergo HIV testing followed by HIV viral load, CD4 count, and HIV genotype/resistance testing.

All patients with HIV should generally be initiated on antiretroviral therapy, regardless of CD4 count.  Additional treatment is then indicated based on the degree of immunodeficiency and serologic testing, as follows:

  • CD4 count ≤200/mm3:  Primary prophylaxis (treatment prior to disease onset) against Pneumocystis pneumonia is required; daily trimethoprim-sulfamethoxazole is the drug of choice.
  • CD4 count ≤100/mm3:  Primary prophylaxis against toxoplasmosis is required in those with positive Toxoplasma serology; daily trimethoprim-sulfamethoxazole is also effective against this disease.
  • Hepatitis serologies:  Hepatitis A and B virus vaccination should be given to those with no evidence of immunity; treatment is required for those with chronic hepatitis B and C infection.
  • Varicella zoster virus serology:  Vaccination is required for those who have never had chicken pox/shingles and have negative serology.

Vaccination against pneumococcus and influenza is also indicated.  Primary prophylaxis (eg, itraconazole) against histoplasmosis is sometimes given for those with CD4 counts ≤150/mm3 in histoplasma-endemic areas (eg, Ohio/Mississippi river valley).  In the past, primary prophylaxis (eg, azithromycin) against mycobacterium avium complex (MAC) was given to those with CD4 counts ≤50/mm3, but this is no longer recommended due to the low incidence of MAC (particularly once antiretroviral therapy is started).

Acyclovir/valacyclovir is used for secondary prophylaxis to prevent herpes simplex virus recurrences in those with frequent outbreaks; these medications are not used as primary prophylaxis.  Although patients with advanced HIV are at increased risk for Candida (eg, oropharyngeal thrush) and cryptococcal infections, fluconazole primary prophylaxis is not recommended due to cost and increased risk of azole drug resistance.

Educational objective:
HIV patients with CD4 counts ≤200 cells/mm3 require primary prophylaxis with trimethoprim-sulfamethoxazole to prevent Pneumocystis pneumonia.  This medication is also used for primary prophylaxis against toxoplasmosis in those with positive serology and CD4 counts ≤100/mm3.  Primary prophylaxis against mycobacterium avium complex (azithromycin) is no longer required.  No other primary prophylaxis is routinely given; however, patients in Histoplasma-endemic areas with CD4 counts ≤150/mm3 are sometimes given prophylactic itraconazole.