A March (@2.1) vs B Stevens (@1.67)
04-10-2019

Our Prediction:

B Stevens will win

A March – B Stevens Match Prediction | 04-10-2019 03:00

For each of the OIs discussed in this report, recommendations are provided that address 1) preventing exposure to opportunistic pathogens, 2) preventing disease, 3) discontinuing primary prophylaxis after immune reconstitution, 4) treating patients with disease, 5) monitoring for adverse effects (including IRIS), 6) managing treatment failure, 7) preventing disease recurrence ("secondary prophylaxis" or chronic maintenance therapy), 8) discontinuing secondary prophylaxis after immune reconstitution, and 9) special considerations during pregnancy. Recommendations are rated by a revised version of the IDSA rating system (Box). In this system, the letters A--E signify the strength of the recommendation for or against a preventive or therapeutic measure, and Roman numerals I--III indicate the quality of evidence supporting the recommendation. The guidelines include eleven tables pertinent to the prevention and treatment of OIs (Tables 1--11), a figure that pertains to the diagnosis of tuberculosis (Figure 1), a figure that describes immunization recommendations (Figure 2), and an appendix that summarizes recommendations pertinent to prevention of exposure to opportunistic pathogens.

Pregnant, HIV-infected women who have evidence of primary toxoplasmic infection or active toxoplasmosis, including TE, should be evaluated and managed during pregnancy in consultation with appropriate specialists (BIII). gondii during pregnancy. gondii normally occurs only with acute infection in the immunocompetent host, case reports have documented occurrences of transmission with reactivation of chronic infection in HIV-infected women with severe immunosuppression (229,231). Although perinatal transmission of T. Because the risk for transmission with chronic infection appears low, routine evaluation of the fetus for infection with amniocentesis or cordocentesis is not indicated. Detailed ultrasound examination of the fetus specifically evaluating for hydrocephalus, cerebral calcifications, and growth restriction should be done for HIV-infected women with suspected primary or symptomatic reactivation of T.

Bacterial pneumonia is a common cause of HIV-associated morbidity. The incidence of bacterial pneumonia among HIV-infected persons is greater than that in the noninfected population (454). In the precombination ART era, the Pulmonary Complications of HIV Infection Study reported that the incidence of bacterial pneumonia ranged was 3.9--7.3 episodes per 100 person-years (455). In the current era, the incidence of bacterial pneumonia in HIV-infected persons has declined (4,456,457).

For pregnant women who have had an OI diagnosed and are not on ART, immediate initiation of ART with OI therapy should be encouraged to minimize the risk for perinatal transmission of HIV (79). Decisions about immediate versus delayed initiation of ART in pregnancy should include consideration of gestational age, maternal HIV RNA levels and clinical condition, and potential toxicities and interactions between ART and OI drugs.

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Histopathology might demonstrate perivascular mononuclear inflammatory infiltration (1175--1178). PML developing in the setting of immune reconstitution related to ART warrants special consideration and presents some differences from classical PML. PML has been reported to occur within the first weeks to months after initiating ART in certain patients (1166,1167). In addition, the likelihood of detecting JCV in CSF might be reduced in these patients compared with classic PML, although this needs further study (1179,1180). These cases are presumed to represent the confluence of subclinical CNS JCV infection and restoration of immune responses to JCV by ART with resultant local immune and inflammatory responses, but other undefined factors might affect PML development in this setting. Additionally, some patients exhibit atypical features that include mass effect of the PML lesions with surrounding edema and on occasion, striking contrast enhancement on MRI. This presentation has been referred to as inflammatory PML or IRIS PML.

Blood vessels near the lesions might appear to be sheathed. Peripheral retinitis might be asymptomatic or present with floaters, scotomata, or peripheral visual field defects. Central retinal lesions or lesions impinging on the macula or optic nerve are associated with decreased visual acuity or central field defects. CMV retinitis is a full-thickness necrotizing retinitis, and the characteristic ophthalmologic appearance is that of fluffy yellow-white retinal lesions, with or without intraretinal hemorrhage, and with little inflammation of the vitreous unless immune recovery with potent ART intervenes (658). Occasionally, CMV retinitis lesions, particularly peripheral lesions, might have a more granular appearance.

Although most HIV-infected persons with early syphilis respond appropriately to standard benzathine penicillin, some specialists recommend two additional weekly benzathine penicillin injections. Enhanced penicillin therapy (i.e., standard benzathine penicillin with high-dose oral amoxicillin and probenecid) did not improve clinical outcome in early-stage syphilis (544) and is not recommended (DII) . HIV-infected persons with early-stage (i.e., primary, secondary, or early-latent) syphilis should receive a single intramuscular (IM) injection of 2.4 million units of benzathine penicillin G (AII). Penicillin remains the treatment of choice for syphilis regardless of HIV status. The benefit of this treatment approach remains unproven.

The most common clinical presentation of leishmaniasis in persons with AIDS is a disseminated visceral disease syndrome, but the distribution varies geographically, reflecting differences in the predominant parasite species. Leishmaniasis can occur in four major syndromes: localized cutaneous, diffuse cutaneous, mucosal, and visceral disease. In Europe, visceral disease has been reported in 95% of cases (87% typical visceral, 8% atypical visceral) (1287). In contrast, in Brazil, mucocutaneous (43%) and cutaneous (20%) are common (1288).

However, inadvertent pregnancy during paternal exposure has not been associated with adverse events (1140). Defects noted in animals include limb abnormalities, craniofacial defects, exencephaly, and anophthalmia. Pregnancies that occur in women taking RBV should be reported to the Ribavirin Pregnancy Registry (800-593-2214 orhttp://www.ribavirinpregnancyregistry.com). RBV is an FDA category X drug because of its teratogenicity at low doses in multiple animal species. RBV should not be used during pregnancy (EIII). Women of childbearing potential and men receiving RBV should be counseled about the risks and need for consistent contraceptive use during and for 6 months after completion of RBV therapy.

Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and AdolescentsRecommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America

The regimen should consist of at least two new drugs not used previously, to which the isolate is susceptible and selected from among the following: EMB, rifabutin, amikacin, or a quinolone (moxifloxacin, ciprofloxacin, or levofloxacin), although data supporting a survival or microbiologic benefit when these agents are added have not been compelling (CIII) (33,405,406,430-434,437,447--450). Clofazimine should not be used because randomized trials have demonstrated lack of efficacy and an association with increased mortality (EII) (430,432,448). On the basis of data related to non-HIV-infected patients being treated for MAC, an injectable agent such as amikacin or streptomycin should be considered (CIII) (438). Whether continuing clarithromycin or azithromycin despite resistance provides additional benefit is unknown. Among patients whose initial treatment for MAC disease has not been successful or who have antimycobacterial drug-resistant MAC disease, optimizing ART is an important adjunct to second-line or salvage therapy for MAC disease (AIII). Other second-line agents (e.g., ethionamide, thiacetazone [not available in the United States], or cycloserine) have been anecdotally combined with clarithromycin and azithromycin as salvage regimens. Because the number of drugs with demonstrated clinical activity against MAC is limited, results of susceptibility testing should be used to construct a new multi-drug regimen. However, their role in this setting is not well defined.

After introduction of ART, serum aminotransferases should be monitored closely; some experts recommend monthly for the first 3--6 months and then every 3 months thereafter. Any association between abnormal aminotransferases and clinical jaundice or synthetic dysfunction (elevated INR) should prompt consultation with a hepatologist. The signs and symptoms are characteristic of hepatitis flares. As with HBV coinfection, in HCV-coinfected persons, IRIS might be manifested by dramatic increases in serum aminotransferases as CD4+ counts rise within the first 6--12 weeks after starting ART.

In vivo studies have suggested a possible role for HHV-6 coinfection in the progression of HIV disease (759,760), but this remains unconfirmed. Both HHV-6 and HIV can simultaneously infect the same CD4+ cells under experimental conditions. Studies evaluating the effect of HHV-6 coinfection on active HIV viral replication in vitro have yielded contradictory results, with some investigations documenting enhanced HIV replication (757), whereas others reported inhibition of HIV replication (758).

Patients with malaria can exhibit various symptoms and a broad spectrum of severity depending upon such factors as the infecting species and level of acquired immunity in the host. As noted previously, HIV-immunosuppressed persons in endemic areas might lose acquired malarial immunity, and HIV-immunosuppressed adults with little or no previous malaria exposure such as travelers might be at increased risk for severe outcomes (1242).

The diagnostic evaluation for TB disease in pregnant women is the same as for nonpregnant adults. Congenital TB infection of the infant might occur but appears to be rare (390). An increase in pregnancy complications and undesirable outcomes (including preterm birth), low birthweight, and intrauterine growth retardation might be observed among pregnant women with either pulmonary or extrapulmonary TB not confined to the lymph nodes, especially when treatment is not begun until late in pregnancy (382--389). Chest radiographs with abdominal shielding result in minimal fetal radiation exposure.