A 34-year-old man is diagnosed as being HIV positive. He was born and brought up in the United Kingdom and is currently fit and well with no past medical history.
At what point should anti-retroviral therapy be started?
Correct Answer E: Start anti-retrovirals in HIV when CD4 < 350 * 106/l.
Anti-retroviral therapy has previously been delayed until CD4 counts were below 200 * 106/l. This was largely due to the toxicity of drugs and fear of resistance developing. Recent guidelines now suggest starting treatment when counts drop below 350 * 106/l.
HIV: anti-retrovirals:
Highly active anti-retroviral therapy (HAART) involves a combination of at least three drugs, typically two nucleoside reverse transcriptase inhibitors (NRTI) and either a protease inhibitor (PI) or a nonnucleoside reverse transcriptase inhibitor (NNRTI). This combination both decreases viral replication but also reduces the risk of viral resistance emerging.
Nucleoside analogue reverse transcriptase inhibitors (NRTI):
Non-nucleoside reverse transcriptase inhibitors (NNRTI):
Protease inhibitors (PI):
You are counselling a 26-year-old man who has recently had a positive HIV test. His most recent CD4 count is 650 cells/mm3.
Which one of the following vaccinations is contraindicated?
Correct Answer A:
HIV: immunization: The Department of Health 'Greenbook' on immunization defers to the British HIV Association for guidelines relating to immunization of HIV-infected adults.
A 62-year-old female with chronic renal failure (GFR = 35 ml/min) is diagnosed as having pulmonary tuberculosis.
What changes need to be made to her anti-tuberculosis regime given her renal impairment?
Correct Answer D:
Tuberculosis: drug side-effects: Common side effects:
Rifampicin:
Isoniazid:
Pyrazinamide:
Ethambutol:
A 63-year-old man who migrated from India 7 months ago is referred to the acute medical unit with a history of headache and pyrexia. A lumbar puncture suggests a diagnosis of meningeal tuberculosis.
What treatment should he be started on?
Correct Answer E: The use of steroids in patients with tuberculous meningitis is supported by a Cochrane review in 2008.
Tuberculosis: drug therapy: The standard therapy for treating active tuberculosis is:
Initial phase - first 2 months (RIPE):
Continuation phase - next 4 months:
The treatment for latent tuberculosis is isoniazid alone for 6 months.
Patients with meningeal tuberculosis are treated for a prolonged period (at least 12 months) with the addition of steroids.
Directly observed therapy with a three times a week dosing regimen may be indicated in certain groups, including:
A 39-year-old female who has recently emigrated from sub-Saharan Africa is screened for tuberculosis. She reports being fit and well with no past medical history and has never had a BCG vaccination. Her chest x-ray is normal so she has a Mantoux test which is positive. An interferon gamma test is also performed which is positive. A HIV test is requested which is negative.
What treatment would you recommend?
Correct Answer A: This patient has latent tuberculosis.
Tuberculosis: drug therapy:
The standard therapy for treating active tuberculosis is:
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