HIV case 2 - zkadhem

[ArchivalUser]

A 32-year-old female presents to the office seeking prenatal care. Her last normal menstrual period began 2 1/2 months before her visit. She believes that she is pregnant and has tested positive with a home pregnancy test. She has been pregnant twice before, with one living child and one spontaneous abortion (G3P1). She is married to the father of the children. She has no
health problems but does smoke half a pack of cigarettes per day. She also admits to occasional alcohol use (1 drink every 2 weeks). She denies oral or intravenous drug use. Besides prenatal vitamins with iron, you recommend:
A) Quitting smoking.
B) Confirming the home pregnancy test with a
serum HCG in your lab.
C) HIV testing and counseling.
D) A and C.
E) All of the above.

The patient consents to HIV testing. Her pregnancy is confirmed, but she is found to be ELISA positive for HIV and Western blot positive for HIV. What does this mean?
A) She has been infected with HIV in the last month.
B) She has a false-positive test for HIV.
C) She has antibodies to HIV and must be immune.
D) She has been infected with HIV longer than 1 month ago.
E) Not enough information to judge: order a p24 antigen and RNA PCR.


Your patient is understandably shaken by the news of this test result. She is most concerned about her unborn child. What should you tell her?
A) Her child is almost certainly also infected.
B) A therapeutic abortion at this point is the only humane thing to do.
C) With proper therapy, the risk of transmission to the child can be lowered to less than 5%.
D) With proper therapy, the risk of transmission to the child can be lowered to 15%.
E) Despite proper therapy, the risk of transmission remains at 25%.

She is somewhat relieved that her baby can be protected, and wants to know what can be done to treat her. She feels fine, and would rather not take medications unless she has to. Some additional laboratory tests are ordered, with the following results:
CD4 count: 756/mm3
HIV viral load: 50,000 copies/mL
Hb: 11.2 g/dL
BUN/Cr: 11 mg/dL/0.7 mg/dL
What should you tell her about HAART in pregnancy?
A) To minimize the risk of transmission to her child,she should start triple antiretroviral therapy as soon as possible.
B) Antiretroviral medications are teratogenic and should be avoided at all costs during pregnancy, except just before delivery.
C) Since her CD4 count is normal and she feels well with no sign of opportunistic infections, starting HAART is not indicated.
D) Her renal function makes HAART relatively contraindicated.
E) Her hemoglobin level makes HAART relatively contraindicated.


She agrees that taking medications to protect the baby is the right thing to do and is ready to start the difficult regimen associated with HAART. What regimen do you recommend?
A) Single-dose ZDV treatment as per peripartum prophylaxis protocol.
B) Any single antiretroviral medication, since they are all similarly effective and minimizing the total doses of drugs is safer for the developing fetus.
C) Any of the standard antiretroviral combinations, because combination therapy is essential for lowering the viral load and minimizing resistance.
D) A select combination of antiretroviral medications, because some drugs are category C and some are category B.
E) Any of the standard antiretroviral combinations, as long as it does not include ZDV, which is a notorious teratogen


The patient is started on HAART and tolerates her regimen well. Repeat laboratory results at a return visit are as follows:
CD4 count: 692/mm3
HIV viral load: 5,000 copies/mL
Hgb: 10.9 g/dL
Her HAART seems to be effective. Her viral load has decreased by 1 log10. What do you recommend regarding Pneumocystis carinii pneumonia (PCP) prophylaxis?
A) She should start prophylaxis with TMP-SMX immediately, because PCP in pregnancy can be
particularly severe.
B) She should start PCP prophylaxis with inhaled pentamidine, because TMP-SMX is contraindicated in pregnancy.
C) PCP prophylaxis is not indicated, since her CD4 count is

[ArchivalUser]

D) PCP prophylaxis is not a major concern for pregnant patients.
E) None of the above.


I will continue the scenario of this case later on

[ArchivalUser]

e/d/d/c/c/c

[ArchivalUser]

e
d
e
a
d
c

Answers plz..thank u

[ArchivalUser]

e,d,c,a,d,c

[ArchivalUser]

e/d/c/c/d/c

[ArchivalUser]

B
D
C
C
D
C.

[ArchivalUser]

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[ArchivalUser]

q1 Discussion
The correct answer is D. Smoking during pregnancy is associated with lower birth weight and preeclampsia, and smoking in the house with a young child is associated with respiratory diseases, especially asthma. Although confirming pregnancy by examination (uterine size or fetal heart tones) and/or urine HCG is appropriate, serum HCG is unnecessary and expensive.
Additionally, when used correctly, home pregnancy tests are highly sensitive and specific. HIV testing and counseling should be routinely offered to all women seeking prenatal care, regardless of their particular social situation. Routine testing for HIV in expectant females has dramatically reduced the HIV prevalence in children in developed countries. Vertical transmission of HIV is still a tremendous problem in Africa and other developing regions of the world. Remember that just testing for HIV antibodies is not enough”the patient must understand the purpose and implications of the test. Pre- and post-test counseling are always included with the blood draw.

q2 Discussion
The correct answer is D. The ELISA is the highly sensitive œscreening HIV antibody test, and the Western blot is the highly specific œconfirmatory test. A positive result for both is a reliable indication for the presence of HIV antibody and indicates infection at some point in the past. Since it can take 4 weeks or more for the generation of antibodies, recent infections may not
test positive. Viral p24 antigen or the RNA PCR can detect HIV before the seroconversion (development of antibodies). Immunity to HIV is very rare. Some patients test positive for the antibody, but the disease does not progress as expected. These individuals have been and are being studied in hopes of identifying a molecular site for an HIV vaccine.

q3 Discussion
The correct answer is C. Although it is possible for HIV to the identified in fetal tissues, the large majority of transmission from mother to child occurs due to exposure to the mother™s blood at the time of birth. The first antiretroviral protocol for reducing this rate of transmission used zidovudine (ZDV) therapy only, and succeeded in lowering the rate from 25% to 8.3%. There are multiple options now, depending upon when the mother presents for prenatal
care (if at all). Ideally, the mother should be well suppressed (undetectable viral load) on combination antiretroviral therapy (HAART). This, combined with perinatal therapy for the newborn, lowers the transmission risk to less than 2% (one study found a 1.4% transmission rate!). If the mother presents for the first time just prior to delivery or in the case of very limited resources (as in Africa), one option is nevirapine. A single dose to the mother (200 mg PO) given at the onset of labor and a single dose to the infant 48“72 hours after birth is as effective as 7 days of ZDV or 7 days of ZDV plus 3TC to both mother and child.

[ArchivalUser]

q4 Discussion
The correct answer is A. The risk of vertical transmission of HIV increases with the following: high maternal viral load, low maternal CD4 count (most important), high clinical disease stage, lack of maternal use of antiretrovirals, increasing duration of ruptured membranes, and vaginal delivery (versus cesarean section, but only if no maternal therapy had previously been given). Therefore, HAART should be considered in all pregnant women, despite their current clinical stage of disease. In nonpregnant patients, therapy is often reserved until CD4 counts drop, viral load is very high, or clinical symptoms are apparent. But the goal here is to prevent transmission to the child. Most
antiretroviral medications are safe (or presumed to be safe) in pregnancy. Clearly, the benefit of preventing morbidity from HIV infection outweighs the risk of most medications. Although the patient™s hemoglobin is low, it does not preclude her from taking therapy. Her renal function is normal.

q5 Discussion
The correct answer is D. Although some antiretroviral medications are labeled category C for use in pregnancy, most antivirals are considered safe in pregnancy. ZDV, although category C, is not a notorious teratogen and in fact was the first medication to be proven to reduce maternal-fetal transmission. If an HIV-infected mother presents late term, without any
prenatal care, perinatal ZDV can be given (but not in a single dose”it is given throughout the third trimester, peripartum, and then to the fetus for 6 weeks). Given the large number of HAART options available, it is reasonable to try category B medications first or hold therapy until the second trimester (if the patient is newly diagnosed with HIV infection). Certain combinations are discouraged in pregnancy. For example, combining stavudine (d4T) and didanosine (ddI) is associated with an increased risk for lactic acidosis and is not ecommended in pregnancy. One should avoid using a single antiretroviral agent, and instead always use them in combination.

q6 Discussion
The correct answer is C. PCP is particularly severe in pregnant patients, but prophylaxis is not generally indicated for CD4 counts >200 cells/mm3. TMPSMX is associated with hyperbillirubinemia in newborns, but is still indicated for PCP prophylaxis. Oral dapsone is another option, as is inhaled pentamidine.