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Slides tutorial : 

Slides tutorial ParasiteOpportunistic infectionOthers

Ascaris lumbricoides : 

Ascaris lumbricoides Slightly oval shape, mamilated thick shell Golden browm color Fertilized egg: a mass of uniformly coarse lecithin granule Unfertilized egg: a mass of disorganized, highly refractile granules of various sizes Treatment Mebendazole 100 mg bid x 5 days or 500 mg once Albendazole 400 mg once

Capillaria philippinensis : 

Capillaria philippinensis Colorless/brown color Peanut-shaped with flattened bipolar plugs Striated shell Treatment Mebendazole 200 mg bid x 20 days Albendazole 400 mg bid X 10 days

Enterobius vermicularis : 

Enterobius vermicularis D-shape, coloress thick shell containing larva Treatment Mebendazole 100 mg x 1 Albendazole 400 mg x 1

Slide 8: 

Relative Sizes of Helminth Eggs

Brugia malayi (microfilaria) : 

Brugia malayi (microfilaria) Long cephalic space (1:2) Kinking body Small uncertain nucleus: overlapping Terminal nuclei

Wuchereria bancrofti (microfilaria) : 

Wuchereria bancrofti (microfilaria) Short cephalic space (1:1) Oval, round nucleus: discrete or separate No terminal nuclei Treatment Diethylcarbamazine (DEC) 6 mg/kg/day x 12 days q 6 month duration 2 years Ivermectin 100-440 mg/kg x 1 Ivermectin 100-440 mg/kg + albendazole 400 mg x 1

Histoplasma capsulatum : 

Histoplasma capsulatum Yeast-like organisms (budding) Round-oval shape Grape-like appearance Extracellular, intracellular, within macrophage

Cryptococcus neoformans : 

Cryptococcus neoformans Large round Encapsulated budding yeast Budding yeast with negatively stained halos (dense polysaccharide capsules) and narrow necked buds

Penicillium maneffei : 

Penicillium maneffei Yeast like organism Pleomorphic: round to sausage shape Central clear septum or binary fission

Rhodococcus equi : 

Rhodococcus equi Gram positive coccobacilli and diplococci Positive modified acid-fast Treatment Erythromycin 2 gm/day Vancomycin 15 mg/kg q 12 hr Imipenem plus rifampicin 10mg/kg/day Others: quinolones, azithromycin, clarithromycin, aminoglycosides, meropenem

Aspergillus species : 

Aspergillus species Septate hyphae Acute angle (dichrotomus) branching

Artifacts : 

Artifacts Artifact crystal violet crystals Misinterpreted with gram positive rods or fungi

Haemophilus species : 

Haemophilus species A tiny of gram negative coccobacilii

Nocardia or Actinomyces species : 

Nocardia or Actinomyces species Long irregular beaded gram positive filaments Branching

Polymicrobial/AnaerobicInfection : 

Polymicrobial/AnaerobicInfection Mixed of gram positive, gram negative, rods and cocci Variable shape

Neisseria gonorrhoeae : 

Neisseria gonorrhoeae Male urethral discharge Many gram negative diplococci, intracellular N. meningitidis Moraxella catarrhalis Acinetobacter species.

Oocyst of Isospora belli : 

Oocyst of Isospora belli Modified acid fast positive Oval shape large size 15-20 mm Some with 1-2 sporocyst inside Treatment Trimethoprim/sulfamethoxazole 160/800 qid x 10 days then bid for 3 weeks

Cutaneous larva migrans or Creeping eruption : 

Cutaneous larva migrans or Creeping eruption Ancylostoma braziliense Ancylostoma caninum Strongyloids stercoralis Ancylostoma duodenale Necator americanus Gnathostoma spinigerum Uncinaria stenocephala Bunostomum phlebotomum Treatment thiabendazole 25 mg/kg bid x 2 days albendazole 400 mg/d x 3-7 days ivermectin 150-200 mg po x 1

Pseudallescheria boydii : 

Pseudallescheria boydii Dichotomous branching septate hyphae

Staining : 

Staining Gram stain Bacteria, Nocardia spp., R. equi, TB, NTM, Fungus, Actinomyces spp. AFB TB, NTM Modified AFB Nocardia spp., TB, R. equi, Cryptosporidium spp., Microsporidium spp., I. belli Wright stain Fungus-yeast, protozoa multinucreated giant cell Fresh Parasite, fungus-mycelium

Treatment of TB in AIDS : 

Treatment of TB in AIDS Isoniazid 300 mg/d Rifampicin 450 – 600 mg/d Ethambutol 800 mg/d Pyrazinamide 1000 – 1500 mg/d Regimen 2IRZE/4IR – upper lobe pul TB, CD4 > 200/mm3 2IRZE/7IR – multiple site TB, pul TB smear still positive after 2 months

Treatment of TB in AIDS : 

Treatment of TB in AIDS SGPT > 3 x UNL, asymptomatic Continue IRZE, repeat SGPT 1 weeks later If SGPT > 5 UNL -> change to RZE x 9-12 mo SGPT > 5 x UNL, clinical hepatitis, jaundice Change to EOS -> no symptoms, no jaundice, SGPT < 3 x UNL -> add rifampicin -> continue REO X 9-12 mo

Treatment of TB in AIDS : 

Treatment of TB in AIDS SGPT < 5 x UNL, but clinical jaundice Change to IEO -> jaundice -> continue 12-18 mo If worsening -> stop INH -> FU 2 wks -> not improve -> work up liver biopsy Severe rash Stop all IRZE, start OS -> challenge I or R first x 3 days -> if no rash -> Z -> E 3 days each

Prevention of TB in AIDS : 

Prevention of TB in AIDS Primary prophylaxis (Rx of latent infection) Suggest only in hospital with active follow up or DOTS Indication PPD > 5 mm or close contact with active TB Regimen INH 300 mg/d x 9 months Secondary prophylaxis None because of low relapse rate (5.5%)

Slide 45: 

Pneumocystis Pneumonia

CXR PCP vs non PCP : 

CXR PCP vs non PCP Onset subacute acute Sputum non-productive productive LN neck none, small large, asym CXR of PCP – perihilar, bilateral diffuse interstitial CXR of non PCP – hilar node, unilateral infiltrate, cavity, pleural effusion

Treatment of PCP : 

Treatment of PCP Cotrimoxazole 15 mg/kg/day of TMP (Cotrimoxazole 1 tab = TMP 80/SMX 400) Duration 21 days if dyspnea, clinical hypoxia required O2 support or ABG PaO2 < 70 mmHg Prednisolone 30-60 mg/d x 7-21 d

Alternative Rx of PCP : 

Alternative Rx of PCP Clindamycin 600 mg iv/po q 8 hr + Primaquin 30 mg/d TMP 15 mg/kg/d + Dapsone 100 mg/d Atovaquone 750 mg po TID Pentamidine 3-4 mg/kg/d iv OD

? Alternative Rx of PCP : 

? Alternative Rx of PCP Azithromycin 500 mg po OD + Primaquin 30 mg/d X 21 d

Prophylaxis of PCP : 

Prophylaxis of PCP Primary prophylaxis CD4 < 200/mm3 AIDS or severe non AIDS symptoms (OC) Secondary prophylaxis Previous PCP Cotrimoxazole 2 tab OD

Prophylaxis of PCP : 

Prophylaxis of PCP Dapsone 100 mg/d Clindamycin 300 mg po TID/Primaquin 15 mg/d Azithromycin 500 mg po OD Desensitize cotrimoxazole Early HAART Duration – lifelong or immune recovery after ARV

Discontinuation of PCP ProphylaxisRecommendations from USPHS/IDSA Guidelines : 

Discontinuation of PCP ProphylaxisRecommendations from USPHS/IDSA Guidelines Setting Primary Prophylaxis Secondary Prophylaxis CD4 > 200 for > 3 months CD4 > 200 for > 3 months Criteria From: MMWR 2001;50 (RR-11):1-52.

Pneumocystis & Immune Reconstitution : 

Pneumocystis & Immune Reconstitution Timing- Typically 7 to 30 days after starting HAART Clinical Manifestations- High grade-fever- Patchy infiltrates- BAL: few Pneumocystis organisms, severe inflammatory foci Treatment - Restart corticosteroids From: Wislez M et al. Am J Respir Crit Care Med 2001;164:847-51.

Slide 54: 

DHS/HIV/PP Cryptococcal Meningitis

Cryptococcal Meningitis: 14-Day Induction Therapy : 

Cryptococcal Meningitis: 14-Day Induction Therapy Initial LP: Reduce opening pressure by 50%Daily LPs: Maintain opening < 200 mm H2OCessation of LPs: once opening pressure normal for several consecutive days Suspected or Confirmed Cryptococcal Meningitis*Serial LPs if Opening Pressure > 200 mm H2O Ampho B0.7-1.0 mg/kg/d

Cryptococcal Meningitis: 10 Wk Consolidation Rx : 

Cryptococcal Meningitis: 10 Wk Consolidation Rx DHS/OI/PP Cryptococcal Meningitis Clinical improved, ambulate, no LP needed Fluconazole400 mg/d

Cryptococcal Meningitis: maintenance Rx : 

Cryptococcal Meningitis: maintenance Rx DHS/OI/PP Cryptococcal Meningitis Clinical silence Fluconazole 200 mg/d

Cryptococcal Meningitis: 10 Wk Consolidation Rx : 

Cryptococcal Meningitis: 10 Wk Consolidation Rx DHS/OI/PP Cryptococcal Meningitis Clinical not improved, frequent LP, Numerous budding yeast Ampho B 1 mg/kg/d + Flu 400 – 800 mg/d x 1-2 wk

Prophylaxis of CM : 

Prophylaxis of CM Primary prophylaxis CD4 < 100/mm3 Cryptococcal antigen - negative Regimen Fluconazole 400 mg po weekly

Prophylaxis of CM : 

Prophylaxis of CM Secondary prophylaxis Previous CM Regimen Fluconazole 200 mg/day

Discontinuation of CM ProphylaxisRecommendations from USPHS/IDSA Guidelines : 

Discontinuation of CM ProphylaxisRecommendations from USPHS/IDSA Guidelines Setting Primary Prophylaxis Secondary Prophylaxis not applicable CD4 > 100 for > 6 months Criteria From: MMWR 2001;50 (RR-11):1-52.

Slide 62: 

DHS/HIV/PP Toxoplasmosis

Treatment of toxoplasmosis : 

Treatment of toxoplasmosis Cotrimoxazole 15 mg/kg/day of TMP + Pyrimethamine 50 mg/d Duration 6-8 weeks if marked cerebral swelling Prednisolone 60 mg/d x 7- 14 d

Alternative Rx of toxoplasmosis : 

Alternative Rx of toxoplasmosis Clindamycin 600 mg iv/po q 8 hr + Pyrimethamine 50 mg/d ? Azithromycin 1000 mg po OD + pyrimethamine 50 mg/d ()

Prophylaxis of toxoplasmosis : 

Prophylaxis of toxoplasmosis Primary prophylaxis CD4 < 100/mm3 (with IgG toxo +ve) Secondary prophylaxis Previous cerebral toxoplasmosis Regimen Cotrimoxazole 2 tab po OD

Prophylaxis of toxoplasmosis : 

Prophylaxis of toxoplasmosis Clindamycin 300 mg po TID/Pyrimethamine 25 mg/d Azithromycin 500 mg po OD Desensitize cotrimoxazole Early HAART Duration – lifelong or immune recovery after ARV

Discontinuation of Toxo ProphylaxisRecommendations from USPHS/IDSA Guidelines : 

Discontinuation of Toxo ProphylaxisRecommendations from USPHS/IDSA Guidelines Setting Primary Prophylaxis Secondary Prophylaxis CD4 > 200 for > 3 months CD4 > 200 for > 6 months and Completed Initial Rx and Asymptomatic for Toxo Criteria From: MMWR 2001;50 (RR-11):1-52.

Slide 69: 

DHS/HIV/PP Mycobacterium avium Complex

Mycobacterium avium complex : 

Mycobacterium avium complex Clinical presentation Advanced AIDS with CD4 < 100/mm3 Persistent fever Anemia, hepatomegaly Negative CXR Elevated Alkaline phosphatase LN or BM AFB +ve

Treatment of MAC : 

Treatment of MAC Azithromycin 500 mg po OD or Clarithromycin 500 mg po BID + Ethambutol 800 mg/d + Ofloxacin 400 mg/d or Cipro 500 mg BID X 3 months continue long-life as secondary prophylaxis or until immune recovery

Primary prophylaxis of MAC : 

Primary prophylaxis of MAC CD 4 < 50/mm3 Azithromycin 1000 mg po weekly or Clarithromycin 250 - 500 mg po BID + Ethambutol 800 mg/d

MAC: Immune Reconstitution Syndrome : 

MAC: Immune Reconstitution Syndrome Low CD4 (< 50): more severe illness; fevers, weight loss, leukocytosis, positive blood cultures (Race, Lancet, 1998) High CD4 (> 100-150): fewer systemic symptoms, more localized suppurative disease (Phillips, JAIDS, 1998) Treatment: continue HAART and MAC therapy, NSAIDS, steroids (for severe symptoms), local surgery?

Discontinuation of MAC ProphylaxisRecommendations from USPHS/IDSA Guidelines : 

Discontinuation of MAC ProphylaxisRecommendations from USPHS/IDSA Guidelines Setting Primary Prophylaxis Secondary Prophylaxis CD4 > 100 for > 3 months CD4 > 100 for > 6 months and Completed 12 months MAC RX and Asymptomatic for MAC Criteria From: MMWR 2001;50 (RR-11):1-52.

Slide 75: 

Cytomegalovirus

Treatment of CMV retinitis : 

Treatment of CMV retinitis Gangciclovir 5 mg/kg iv q 12 hr x 14 days or inactive retinal lesions then Intravitreous ganciclovir 1000 ug q 1-2 weeks HAART start at D1-7 of ganciclovir Rx Visual impairment may improve only 30 -70% Blindness or retinal detachment not improved

Prophylaxis of CMV retinitis : 

Prophylaxis of CMV retinitis Primary prophylaxis Not realistic in Thailand Regular screening of eyes Early start ARV in advanced AIDS Secondary prophylaxis Also not practical in Thailand Gangciclovir intravitreous 1-2 weekly Early start ARV

Discontinuation of CMV ProphylaxisRecommendations from USPHS/IDSA Guidelines : 

Discontinuation of CMV ProphylaxisRecommendations from USPHS/IDSA Guidelines Setting Primary Prophylaxis Secondary Prophylaxis Not Applicable CD4 > 100-150 for > 6 months and No evidence of active disease and Regular ophtho examinations Criteria From: MMWR 2001;50 (RR-11):1-52.

Slide 80: 

Esophageal Candidiasis

Treatment of Oropharyngeal Candidiasis : 

Treatment of Oropharyngeal Candidiasis Cotrimazole vaginal tab ½ x 3 – 5 /day Fluconazole 200 -400 mg PO qd Duration 3-5 days or until thrush disappears DHS/HIV/OIs/PP Dose

Treatment of Esophageal Candidiasis : 

Treatment of Esophageal Candidiasis Fluconazole 200 -400 mg PO qd Itraconazole Solution 100 mg PO bid Amphotericin B 0.3-0.7 mg/kg IV qd Duration - 7-14 days DHS/HIV/OIs/PP Dose

Slide 83: 

DHS/HIV/PP Cryptosporidium Cyclospora Isospora Microsporidium

Cryptosporidiosis: Treatment : 

Cryptosporidiosis: Treatment HAART Antimicrobial Agents- Paromomycin- Azithromycin 500 mg po OD - Nitazoxanide Antimotility Agents From: Chen X-M, et al. N Engl J Med 2002;346;1723-31.

Isospora, cyclospora: Treatment : 

Isospora, cyclospora: Treatment Cotrimoxazole 15-20 mg TMP /kg/d OR Ofloxacin 400 mg/d Duration 14 -21 days From: Chen X-M, et al. N Engl J Med 2002;346;1723-31.

Microsporidium: Treatment : 

Microsporidium: Treatment Can cause chronic diarrhea concurrent with other parasites Only Encephalitozoon spp. can response to albendazole 800 mg/d until start ARV From: Chen X-M, et al. N Engl J Med 2002;346;1723-31.

Slide 87: 

DHS/HIV/PP Penicillium marneffei Histoplasma capsulatum

Slide 88: 

H. capsulatum small budding yeasts intracellular and extracellular, grapelike

Slide 89: 

P. marneffei Small oval , round , sausage shaped yeast with central clear septum ( binary fission)

Treatment of P. marneffei & H. capsulatum : 

Treatment of P. marneffei & H. capsulatum Amphotericin 0.7 mg/kg/day for 14 days then change to itraconazole 400 mg/d for 12 weeks then reduce to 200 mg/day for maintenance or secondary prophylaxis

Prophylaxis of P. marneffei & H. capsulatum : 

Prophylaxis of P. marneffei & H. capsulatum Primary prophylaxis CD 4 < 100/ mm3 Regimen Itraconazole 200 mg/d until ARV -> CD4> 100/mm3

Slide 92: 

DHS/HIV/PP Herpes simplex Herpes zoster

Treatment of Herpes simplex & Herpes zoster : 

Treatment of Herpes simplex & Herpes zoster Herpes simplex Acyclovir (200) 2x3 po x 5-7 days Herpes zoster Acyclovir (200) 4x5 po x 7-14 days

Slide 94: 

DHS/HIV/PP Pruritic papular eruption (PPE)

Treatment of PPE : 

Treatment of PPE 0.1% TA cream topical prn Atarax or histan 1x prn

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