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The Inpatient with AIDS: What the Hospitalist Needs to Know

Progressive multifocal leukoencephalopathy (PML) is characterized radiographically by multiple and bilateral hypodense lesions of the white matter without mass effect or enhancement on CT. MRI demonstrates areas of hypointensity on T1-weighted images and increased intensity on T2-weighted images. JC virus DNA can be detected by PCR of CSF or brain tissue with sensitivity of approximately 80% and specificity of 95%. Because of the high positive predictive value of a positive PCR, a patient with AIDS who also has a compatible MRI can be diagnosed with PML (44,45).

Other focal neurologic disease seen in AIDS patients includes cryptococcomas, tuberculomas, CMV encephalitis, neurosyphilis, Nocardia and Aspergillus infection, and bacterial brain abscesses (46).

Conclusion

As survival of the HIV-infected population improves, more patients may require hospitalization for HAART treatment failures or complications attributed to antiretroviral therapy. The hospitalist should be familiar with the complications of antiretroviral agents, the interactions between HAART and medications used to treat opportunistic infections, and medical conditions induced by HAART. Evaluation of the HIV-infected patient presenting with fever can be based on the CD4 cell count, which predicts risk for opportunistic infections. Finally, using combined diagnostic approaches along with modern imaging and laboratory assays may preclude the need for more invasive procedures in the HIV-infected hospitalized patient.

Dr. Decker may be reached at [email protected].

References

  1. Torres RA, Barr M. Impact of combination therapy for HIV infection on inpatient census. N Engl J Med. 1997;336:1531-2.
  2. Fleishman JA, Hellinger FJ. Trends in HIV-related inpatient admissions from 1993 to 1997: a seven-state study. J Acquir Immune Defic Syndr. 2001;28:73-80.
  3. Fleishman JA, Hellinger FH. Recent trends in HIV-related inpatient admissions 1996-2000: a 7-state study. J Acquir Immune Defic Syndr. 2003;34:102-10.
  4. Powderly WG. Should patients with an acute opportunistic infection receive antiretroviral therapy immediately? Advanced Studies in Medicine. 2005;5:S111-S116.
  5. Fagard C, Oxenius A, Gunthard H, et al. A prospective trial of structured treatment interruptions in human immunodeficiency virus infection. Arch Intern Med. 2003;163:1220-6.
  6. Soni N, Pozniak A. Continuing HIV therapy in the ICU. Crit Care. 2001;5:247-8.
  7. Purdy BD, Raymond AM, Lesar TS. Antiretroviral prescribing errors in hospitalized patients. Ann Pharmacother. 2000;34:833-8.
  8. Autran B, Carcelain G, Li TS, et al. Positive effects of combined antiretroviral therapy on CD4+ T cell homeostasis and function in advanced HIV disease. Science. 1997;277:112-6.
  9. Cooney EL. Clinical indicators of immune restoration following highly active antiretroviral therapy. Clin Infect Dis. 2002;34:224-33.
  10. Hirsch HH, Kaufmann G, Sendi P, BaĴegay M. Immune reconstitution in HIV-infected patients. Clin Infect Dis. 2004;38:1159-66.
  11. Cheng VC, Yuen KY, Chan WM, Wong SS, Ma ES, Chan RM. Immunorestitution disease involving the innate and adaptive response. Clin Infect Dis. 2000;30:882-92.
  12. Fishman JE, Saraf-Lavi E, Narita M, Hollender ES, Ramsinghani R, Ashkin D. Pulmonary tuberculosis in AIDS patients: transient chest radiographic worsening after initiation of antiretroviral therapy. AJR Am J Roentgenol. 2000;174:43-9.
  13. Piscitelli SC, Gallicano KD. Interactions among drugs for HIV and opportunistic infections. N Engl J Med. 2001;344:984-96.
  14. Barry M, Mulcahy F, Merry C, Gibbons S, Back D. Pharmacokinetics and potential interactions amongst antiretroviral agents used to treat patients with HIV infection. Clin Pharmacokinet. 1999;36:289-304.
  15. Sim SM, Hoggard PG, Sales SD, Phiboonbanakit D, Hart CA, Back DJ. Effect of ribavirin on zidovudine efficacy and toxicity in vitro: a concentration-dependent interaction. AIDS Res Hum Retroviruses. 1998;14:1661-7.
  16. Clarke SM, Mulcahy FM, Tjia J, et al. The pharmacokinetics of methadone in HIV-positive patients receiving the non-nucleoside reverse transcriptase inhibitor efavirenz. Br J Clin Pharmacol. 2001;51:213-7.
  17. Centers for Disease Control and Prevention. Updated guidelines for the use of rifabutin or rifampin for the treatment and prevention of tuberculosis among HIV-infected patients taking protease inhibitors or nonnucleoside reverse transcriptase inhibitors. Morb Mortal Wkly Rep. 2000;49:185-9.
  18. Havlir DV, O’Marro SD. Atazanavir: new option for treatment of HIV infection. Clin Infect Dis. 2004;38:1599-604.
  19. Sheng WH, Hsieh SM, Lee SC, et al. Fatal lactic acidosis associated with highly active antiretroviral therapy in patients with advanced human immunodeficiency virus infection in Taiwan. Int J STD AIDS. 2004;15:249-53.
  20. Herman JS, Easterbrook PJ. The metabolic toxicities of antiretroviral therapy. Int J STD AIDS. 2001;12:555-62;quiz 563-4.
  21. Behrens G, Schmidt H, Meyer D, Stoll M, Schmidt RE. Vascular complications associated with use of HIV protease inhibitors. Lancet. 1998;351:1958.
  22. Klein D, Hurley LB, Sidney S. Cardiovascular Disease and HIV Infection. N Engl J Med. 2003;349:1869-70; author reply 1869-70.
  23. Friis-Moller N, Sabin CA, Weber R, et al. Combination antiretroviral therapy and the risk of myocardial infarction. N Engl J Med. 2003;349:1993-2003.
  24. Anderson JA, Adkinson NF Jr. Allergic reactions to drugs and biologic agents. JAMA. 1987;258:2891-9.
  25. Hewitt RG. Abacavir hypersensitivity reaction. Clin Infect Dis. 2002;34:1137-42.
  26. Hetherington S, Hughes AR, Mosteller M, et al. Genetic variations in HLA-B region and hypersensitivity reactions to abacavir. Lancet. 2002;359:1121-2.
  27. Bossi P, Colin D, Bricaire F, Caumes E. Hypersensitivity syndrome associated with efavirenz therapy. Clin Infect Dis. 2000;30:227-8.
  28. Bourezane Y, Salard D, Hoen B, Vandel S, Drobacheff C, Laurent R. DRESS (drug rash with eosinophilia and systemic symptoms) syndrome associated with nevirapine therapy. Clin Infect Dis. 1998;27:1321-2.
  29. Walensky RP, Goldberg JH, Daily JP. Anaphylaxis after rechallenge with abacavir. AIDS. 1999;13:999-1000.
  30. Martin GJ, Paparello SF, Decker CF. A severe systemic reaction to trimethoprim-sulfamethoxazole in a patient infected with the human immunodeficiency virus. Clin Infect Dis. 1993;16:175-6.
  31. Bersoff-Matcha SJ, Miller WC, Aberg JA, et al. Sex differences in nevirapine rash. Clin Infect Dis. 2001;32:124-9.
  32. Kopp JB, Falloon J, Filie A, et al. Indinavir-associated interstitial nephritis and urothelial inflammation: clinical and cytologic findings. Clin Infect Dis. 2002;34:1122-8.
  33. Geene D, Sudre P, Anwar D, Goehring C, Saaidia A, Hirschel B. Causes of macrocytosis in HIV-infected patients not treated with zidovudine. Swiss HIV Cohort Study. J Infect. 2000;40:160-3.
  34. Gottesman L. Sustiva may cause false positive on marijuana test. WORLD. 1999:7.
  35. Sepkowitz KA, Telzak EE, Carrow M, Armstrong D. Fever among outpatients with advanced human immunodeficiency virus infection. Arch Intern Med. 1993;153: 1909-12.
  36. Barat LM, Gunn JE, Steger KA, Perkins CJ, Craven DE. Causes of fever in patients infected with human immunodeficiency virus who were admitted to Boston City Hospital. Clin Infect Dis. 1996;23:320-8.
  37. Sepkowitz KA. FUO and AIDS. Curr Clin Top Infect Dis. 1999;19:1-15.
  38. Asawavichienjinda T, Sitthi-Amorn C, Tanyanont V. Serum cyrptococcal antigen: diagnostic value in the diagnosis of AIDS-related cryptococcal meningitis. J Med Assoc Thai. 1999;82:65-71.
  39. Richards PJ, Riddell L, Reznek RH, Armstrong P, Pinching AJ, Parkin JM. High resolution computed tomography in HIV patients with suspected Pneumocystis carinii pneumonia and a normal chest radiograph. Clin Radiol. 1996;51:689-93.
  40. Gruden JF, Huang L, Turner J, et al. High-resolution CT in the evaluation of clinically suspected Pneumocystis carinii pneumonia in AIDS patients with normal, equivocal, or nonspecific radiographic findings. AJR Am J Roentgenol. 1997;169:967-75.
  41. MacMahon EM, Glass JD, Hayward SD, et al. Association of Epstein-Barr virus with primary central nervous system lymphoma in AIDS. AIDS Res Hum Retroviruses. 1992;8:740-2.
  42. Rao CR, Jain K, Bhatia K, Laksmaiah KC, Shankar SK. Association of primary central nervous system lymphomas with the Epstein-Barr virus. Neurol India. 2003;51:237-40.
  43. Antinori A, De Rossi G, Ammassari A, et al. Value of combined approach with thallium-201 single-photon emission computed tomography and Epstein-Barr virus DNA polymerase chain reaction in CSF for the diagnosis of AIDS-related primary CNS lymphoma. J Clin Oncol. 1999;17:554-60.
  44. Post MJ, Yiannoutsos C, Simpson D, et al. Progressive multifocal leukoencephalopathy in AIDS: are there any MR findings useful to patient management and predictive of patient survival? AIDS Clinical Trials Group, 243 Team. AJNR Am J Neuroradiol. 1999;20:1896-906.
  45. Weber T. Cerebrospinal fluid analysis for the diagnosis of human immunodeficiency virus-related neurologic diseases. Semin Neurol. 1999;19:223-33.
  46. Skiest DJ. Focal neurological disease in patients with acquired immunodeficiency syndrome. Clin Infect Dis. 2002;34:103-15.
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