ACRN Opportunistic Infections Management 2 — Questions and Answers
Question 1: What is the first-line induction treatment for cryptococcal meningitis in HIV patients?
- Fluconazole alone
- Itraconazole plus voriconazole
- Amphotericin B plus flucytosine (Correct answer)
- Voriconazole plus caspofungin
Correct answer: Amphotericin B plus flucytosine
The induction phase for cryptococcal meningitis requires amphotericin B deoxycholate (or liposomal) plus flucytosine for at least 2 weeks, followed by fluconazole consolidation.
Question 2: A patient on TMP-SMX for PCP prophylaxis develops a severe sulfonamide allergy. What is the most appropriate alternative?
- Fluconazole
- Azithromycin
- Dapsone or atovaquone (Correct answer)
- Ganciclovir
Correct answer: Dapsone or atovaquone
Dapsone and atovaquone are both acceptable alternatives for PCP prophylaxis in patients who cannot tolerate TMP-SMX due to sulfa allergy.
Question 3: Which medication regimen is recommended for MAC prophylaxis in HIV patients with CD4 < 50 cells/mm³?
- Daily TMP-SMX double-strength
- Weekly azithromycin or daily clarithromycin (Correct answer)
- Daily isoniazid
- Daily fluconazole
Correct answer: Weekly azithromycin or daily clarithromycin
Weekly azithromycin (1200 mg) or daily clarithromycin (500 mg BID) are the preferred macrolide-based regimens for MAC prophylaxis at CD4 < 50 cells/mm³.
Question 4: What is the treatment of choice for CMV retinitis in HIV-positive patients?
- Acyclovir IV
- Foscarnet only
- Ganciclovir IV or oral valganciclovir (Correct answer)
- TMP-SMX
Correct answer: Ganciclovir IV or oral valganciclovir
Ganciclovir (IV) or its oral prodrug valganciclovir is the standard of care for induction and maintenance treatment of CMV retinitis.
Question 5: Which diagnostic test is considered the gold standard for confirming active pulmonary tuberculosis in an HIV-positive patient?
- Tuberculin skin test (TST)
- QuantiFERON-TB Gold assay
- Chest X-ray with cavitation
- Sputum acid-fast bacilli (AFB) culture (Correct answer)
Correct answer: Sputum acid-fast bacilli (AFB) culture
Sputum AFB culture remains the gold standard for TB diagnosis because TST and IGRA may be falsely negative in severely immunocompromised HIV patients.
Question 6: A nurse caring for an HIV patient who starts ART notices the patient develops worsening lymphadenopathy and fever. The patient was recently diagnosed with MAC. What is the most likely explanation?
- ART drug toxicity reaction
- New opportunistic infection
- Immune Reconstitution Inflammatory Syndrome (IRIS) (Correct answer)
- MAC treatment failure
Correct answer: Immune Reconstitution Inflammatory Syndrome (IRIS)
IRIS occurs when the recovering immune system mounts an exaggerated inflammatory response to a pre-existing OI like MAC after ART is initiated.
Question 7: When can PCP prophylaxis be safely discontinued in an HIV patient on ART?
- When viral load becomes undetectable
- When CD4 count rises above 200 cells/mm³ and remains there for at least 3 months (Correct answer)
- When the patient has been on ART for 6 months
- When the patient has no OI symptoms for 1 year
Correct answer: When CD4 count rises above 200 cells/mm³ and remains there for at least 3 months
PCP prophylaxis can be safely stopped when the CD4 count has sustained above 200 cells/mm³ for at least 3 months on effective ART, indicating immune reconstitution.
ACRN Opportunistic Infections Management 2
What is the first-line induction treatment for cryptococcal meningitis in HIV patients?