INITIAL CARE: GENERAL CONSIDERATIONS
The spectrum of disease caused by HIV infection varies, from those coming to the ED with asymptomatic infection for symptoms unrelated to HIV disease, to symptomatic patients seeking care from involvement of virtually any organ system and with multiple coexisting symptoms. This makes the ED evaluation and diagnosis of HIV-positive patients challenging.
Maintain confidentiality regarding HIV-related diagnoses in the ED. Begin care without discrimination and without assuming any illness trajectory unless advanced directives, including cardiopulmonary resuscitation, are already in place.
Always use universal precautions (in some hospitals termed standard precautions). Healthcare workers are often exposed to the blood and body fluids of HIV-infected patients or patients at high risk of harboring the HIV virus. ED-based studies have demonstrated that substantial numbers of patients continue to have unsuspected HIV infection and that HIV seropositivity cannot be predicted accurately, even after assessment of risk factors.
Occupational exposure is covered in the chapter 162, "Occupational Exposures, Infection Control, and Standard Precautions." Testing, treatment, and follow-up are discussed. Other resources for information on HIV exposures are the Centers for Disease Control and Prevention and the University of California, San Francisco National Clinicians' Post-Exposure Prophylaxis Hotline (888-448-4911, http://www.nccc.ucsf.edu).15
Focus the history taking and physical examination on identifying the clinical stage of disease to direct attention to the most likely complications. Obtain a thorough report of past and current medications and previous infections, and ask about the patient's ability to perform activities of daily living. A directed exam seeks findings of organ involvement related to the chief complaint. Physical findings that might specifically assist with staging include the presence of oral candidiasis, skin lesions, temporal wasting, and dementia.
Diagnosis and treatment are directed toward recognition of infection (when not previously diagnosed), assessment of the severity of disease, identifying specific organ(s) involved, and institution of therapy. For the most up-to-date information and details on drug dosing, sources include the Centers for Disease Control and Prevention Web site16 or the Johns Hopkins University School of Medicine guide to care of the HIV-positive patient.8
Consultation with an infectious disease specialist and others with expertise in HIV infection is often necessary to provide proper therapy and disposition. Disposition decisions are based on the need for inpatient evaluation or management and the patient's ability to function as an outpatient, which is often driven by oral intake and ambulation ability and availability of appropriate medical follow-up. Healthcare and family resources can aid decision making about care.
Systemic symptoms such as fever, weight loss, and malaise are common in HIV-infected patients and account for the majority of HIV-related ED presentations.8 In the ED, look for systemic infection, malignancy, drug toxicity, or metabolic abnormalities. This is done by assessing serum electrolytes with renal function, CBC, liver function studies, blood cultures, urinalysis and urine culture, hepatic function tests, and chest radiograph; serologic testing for syphilis, cryptococcosis, toxoplasmosis, cytomegalovirus infection, and coccidioidomycosis is deployed more selectively. Lumbar puncture is needed after neuroimaging if headache, altered sensorium, visual change, or other focal neurologic symptoms or signs are present.
When treating the febrile ill-appearing HIV patient, provide fluid resuscitation, prompt empiric antibiotics, and admission for further evaluation and management. Outpatient evaluation and treatment are indicated only when all of the following conditions are met: the source of the fever does not dictate admission, the patient is able to function adequately at home (e.g., can maintain sufficient oral intake), and timely medical follow-up can be arranged.
HIV STAGE AND CAUSES OF FEVER
Infections are the most common cause of hospitalization among HIV-infected persons. In HIV-infected persons without obvious localizing signs or symptoms, sources of fever vary by stage of disease. Patients with CD4+ T-cell counts of >500 cells/mm3 generally have causes of fever similar to those in nonimmunocompromised patients, whereas those with CD4+ T-cell counts between 200 and 500 cells/mm3 are most likely to have early bacterial respiratory infections. For patients with CD4+ T-cell counts of <200 cells/mm3, the most common causes of fever without obvious localizing findings are early Pneumocystis jirovecii pneumonia (formerly known as Pneumocystis carinii); central line infection; infection with Mycobacterium avium complex, Mycobacterium tuberculosis, or cytomegalovirus; drug fever; and sinusitis. Other causes of fever include endocarditis, lymphoma, and infection with Histoplasma capsulatum or Cryptococcus neoformans. Fever caused by HIV infection alone tends to occur in the afternoon or evening and generally is responsive to antipyretics.
Disseminated M. avium complex infection occurs predominantly in patients with CD4+ T-cell counts of ≤100 cells/mm3 and not on antiretroviral therapy or azithromycin prophylaxis. Persistent fever and night sweats are typical symptoms. Associated symptoms include weight loss, diarrhea, malaise, and anorexia. Dissemination to the bone marrow, liver, and spleen results in anemia and elevated alkaline phosphatase levels. Diagnosis may be made by acid-fast stain of stool or other body fluids or by blood culture. Cultures using the lysis-centrifugation method are more sensitive for M. avium complex (and histoplasmosis) and should be ordered for patients with late-stage disease and fever of unknown origin. Treatment for M. avium complex reduces bacteremia and improves symptoms but does not eradicate disease; it starts with clarithromycin combined with ethambutol and rifabutin. Azithromycin is an alternative therapy.
Immune reconstitution inflammatory syndrome mimics an autoimmune event, with lymphadenitis, fever, and other symptoms commonly starting weeks to months after beginning antiretroviral therapy, often during tuberculosis therapy. Current treatment guidelines advise continuing antiretroviral therapy; nonsteroidal anti-inflammatory agents are recommended for mild to moderate cases; in severe cases, corticosteroids are advised (prednisone 1 to 2 milligrams/kg or equivalent for 1 to 2 weeks). Add the appropriate antimicrobials if there is a known or suspected infection.
Cytomegalovirus is a common cause of serious opportunistic viral disease in HIV-infected patients. Disseminated disease commonly involves the GI, pulmonary, and central nervous systems. The most important manifestation is retinitis (see "Cytomegalovirus Retinitis" below). Treatment is with foscarnet or ganciclovir. Oral ganciclovir can be used for prophylaxis (Table 154-2).
TABLE 154-2Treatment Recommendations for Common Human Immunodeficiency Virus–Related Infections ||Download (.pdf) TABLE 154-2 Treatment Recommendations for Common Human Immunodeficiency Virus–Related Infections
|Organ System ||Infection ||Therapy |
|Systemic ||Mycobacterium avium-intracellulare || |
Clarithromycin, 500 milligrams PO twice a day
Ethambutol, 15 milligrams/kg PO once a day
Rifabutin, 300 milligrams/kg PO once a day
|CMV infection || |
Ganciclovir, 5 milligrams/kg IV twice a day for 2 wk, then 5 milligrams/kg/d
Foscarnet, 90 milligrams/kg every 12 h for 3 wk, then 90 milligrams/kg once a day
|Pulmonary ||Pneumocystis jiroveci (Pneumocystis carinii) pneumonia || |
Trimethoprim-sulfamethoxazole dose using 15–20 milligrams of trimethoprim component per kilogram per day PO or IV in divided doses three times a day for 3 wk
If partial pressure of arterial oxygen is <70 mm Hg or alveolar-arterial gradient is >35 mm Hg, then add
Prednisone, 40 milligrams twice a day for 5 d, then 40 milligrams once a day for 5 d, then 20 milligrams once a day for 11 d
Pentamidine, 4 milligrams/kg/d IV or IM for 3 wk
|Mycobacterium tuberculosis infection* || |
Isoniazid, 5 milligrams/kg PO once a day
Rifampin, 10 milligrams/kg PO once a day or rifabutin 5 milligrams/kg PO once a day
Pyrazinamide, 15–30 milligrams/kg PO once a day
Ethambutol, 15–20 milligrams/kg PO once a day
|Central nervous ||Toxoplasmosis† || |
Pyrimethamine, 200-milligram loading dose PO followed by 50–75 milligrams PO once a day for 6–8 wk
Sulfadiazine, 1–1.5 grams PO every 6 h for 6–8 wk
Leucovorin, 10–25 milligrams once a day
|Cryptococcosis‡ || |
Amphotericin B, 0.7 milligram/kg IV once a day for 2 wk
Flucytosine, 25 milligrams/kg IV four times a day for 2 wk
Fluconazole, 400 milligrams/d PO for 8–10 wk
|Ophthalmologic ||CMV infection# || |
Valganciclovir, 900 milligrams PO twice a day for 14–20 d of induction therapy, then 900 milligrams PO daily for maintenance therapy
Ganciclovir, 2 milligrams intravitreal injection 1–4 doses over 7–10 d for patients with immediately sight-threatening lesions
Foscarnet, 2.4 milligrams intravitreal injection 1–4 doses over 7–10 d for patients with immediately sight-threatening lesions
|GI ||Candidiasis (thrush–limited to mouth) || |
Clotrimazole, 10-milligram troches five times a day
Nystatin, 500,000 units five times a day, gargle
|Esophagitis (primarily Candida) ||Fluconazole, 100–400 milligrams/d PO |
|Salmonellosis† ||Ciprofloxacin, 500 milligrams PO twice a day for 2–4 wk |
|Cryptosporidiosis ||No known effective cure; best results with highly active antiretroviral therapy |
|Cutaneous ||Herpes simplex || |
Acyclovir, 200 milligrams PO five times a day for 7 d
Famciclovir, 125 milligrams PO twice a day for 7 d
Valacyclovir, 1 gram PO twice a day for 7 d
or for severe disease
Acyclovir, 5–10 milligrams/kg IV every 8 h for 7 d
|Herpes zoster || |
Acyclovir, 800 milligrams PO five times a day for 7–10 d
Famciclovir, 500 milligrams PO three times a day for 7–10 d
Valacyclovir, 1 gram PO three times a day for 7–10 d
or for ocular or disseminated disease
Acyclovir, 5–10 milligrams/kg PO every 8 h for 5–7 d
|Candida or Trichophyton infection || |
Topical clotrimazole two or three times a day for 3 wk
Topical miconazole two or three times a day for 3 wk
Topical ketoconazole two or three times a day for 3 wk
Fever in injection drug users is suspicious for infective endocarditis, which often has a nonspecific presentation in the ED (see chapter 155, "Endocarditis"). Most ED physicians admit febrile injection drug users while awaiting the results of blood cultures and echocardiography given the high morbidity and mortality coupled with the difficulties encountered with outpatient follow-up in the drug user population.
Noninfectious causes of fever in HIV patients include neoplasm and drug fever. Non-Hodgkin's lymphoma is the most frequently occurring neoplasm and is characterized by high-grade, rapidly growing mass lesions. New CNS symptoms, particularly a change in mental status in the presence of fever, require neuroimaging. Definitive diagnosis requires biopsy. Radiotherapy and chemotherapy are effective treatment regimens. Drug fever may be secondary to injection drug abuse or adverse drug reactions (see below).