Take you time, **ck your thumb but get it right !! - triplehelix

[ArchivalUser]

65.
A 40-year-old man with AIDS has a 1-day history of blurred vision of the right eye and a several-hour history of acute loss of vision on the right. For the past 6 months, his antiretroviral regimen has included a nucleoside reverse transcriptase inhibitor, a non-nucleoside reverse transcriptase inhibitor, and a protease inhibitor. The patient's most recent CD4 cell count was 355/μL (0.35 × 109/L), and his plasma HIV RNA viral load was 15,000 copies/mL. He has been unwilling to change therapy or to be more compliant with his drug regimen. Medical history is otherwise unremarkable.

On physical examination, vital signs are normal. Ophthalmologic examination discloses pupils that are equal and readily reactive to light. Examination of the right fundus shows a localized area of hemorrhagic necrosis of the fovea. There are no cotton-wool exudates and no uveal disorders. The remainder of the examination is normal.

After hospitalizing the patient, which of the following intravenous agents is most appropriate?

A Pyrimethamine plus oral sulfadiazine
B Acyclovir
C Ganciclovir
D Penicillin
E A corticosteroid

[ArchivalUser]

A

[ArchivalUser]

its A or B...........toxo and VZV cause hemorrhagic lesions in AIDS.......no cotton wool and the CD 4 excludes CMV......even toxo unlikely with this count

will go with B.........acute VZ retinitis..........acuteness main

[ArchivalUser]

C--------or ------------B

[ArchivalUser]

c .herpes

[ArchivalUser]

agree with ronaldo..
if one can assume no vitreous involvement, its unlikely to be toxo.. remember 'headlights in the fog' in active toxo vitritis..
Ganciclovir is usually used for CMV.. here the CD4 count probably rules that out.. likely with counts < 50 /μL
its likely Acute Retinal Necrosis, but the h/o HIV is what throws you off.. ARN usu occurs in healthy individuals... less likely its PORN again due to the CD4 count.. for which the Rx is i/v Acyclovir. 24-48 hours after anti-viral Rx, we usually start anti-inflammatory agents like Prednisone and Aspirin to reduce platelet aggregation.
So my guess is B..

[ArchivalUser]

BBBBBBBb

[ArchivalUser]

Correct answer is B.

This patient has acute retinal necrosis, which occurs most often in patients with HIV infection or AIDS. It is most likely caused by varicella-zoster virus or possibly by herpes simplex virus. The preferred treatment for either of these viruses is intravenous acyclovir.

Intravenous pyrimethamine and oral sulfadiazine are used to treat toxoplasmosis, which this patient is unlikely to have because his HIV infection is under control and he is therefore at significantly less risk for developing opportunistic infections. Intravenous ganciclovir is used to treat cytomegalovirus retinitis, which is also an opportunistic infection and is therefore unlikely in this patient. In addition, his ophthalmologic examination is inconsistent with retinitis, which causes floaters and photopsia (flashing lights) in addition to blurring and loss of vision. Intravenous penicillin is the agent of choice for syphilis. Corticosteroids are used to treat uveal disease, which is most likely in a patient with herpes zoster ophthalmicus.