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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor=Anonymous (Edited by Ayokunle Olubaniyi and Alison Leibowitz)
|ExamType=USMLE Step 2 CK
|ExamType=USMLE Step 2 CK
|MainCategory=Internal medicine
|MainCategory=Internal medicine
|SubCategory=Infectious Disease, Infectious Disease
|SubCategory=Infectious Disease, Infectious Disease
|MainCategory=Internal medicine
|Prompt=A 23-year-old HIV-positive woman recently started on HAART therapy comes to the health center for a checkup. Her CD4 count has been decreasing over the last 5 months, although she remains asymptomatic. Physical examination is unremarkable but her current CD4 count is 192 cells/mm<sup>3</sup>.  
|SubCategory=Infectious Disease, Infectious Disease
 
|MainCategory=Internal medicine
Which of the following prophylactic medications is most appropriate at this time?
|SubCategory=Infectious Disease, Infectious Disease
|Explanation=Pneumocystis pneumonia (PCP) is relatively rare in people with normal immune systems but common among people with weakened immune systems, such as premature or severely malnourished children, the elderly, and especially AIDS patients, in whom it is most commonly observed today.  PCP can also develop in patients who are taking immunosuppressive medications (e.g. patients who have undergone solid organ transplantation) and in patients who have undergone bone marrow transplantation.
|MainCategory=Internal medicine
 
|MainCategory=Internal medicine
HIV-infected adults and adolescents, including pregnant women and those on antiretroviral therapy, should receive chemoprophylaxis against PCP if they have a CD4+ count of <200 cells/µL (AI).  The drug of choice is [[trimethoprim/sulfamethoxazole]] (TMP-SMX).
|SubCategory=Infectious Disease, Infectious Disease
|AnswerA=[[Isoniazid]] and [[rifampin]].
|MainCategory=Internal medicine
|AnswerAExp=These are used in the treatment of [[tuberculosis]].
|SubCategory=Infectious Disease, Infectious Disease
|AnswerB=[[Penicillin G]]
|MainCategory=Internal medicine
|AnswerBExp=This is usually used to treat syphilis in HIV-positive patients.  It is not used as a prophylactic medication against PCP.
|SubCategory=Infectious Disease, Infectious Disease
|AnswerC=[[Valacyclovir]].
|MainCategory=Internal medicine
|AnswerCExp=[[Valaciclovir]] is effective in preventing [[cytomegalovirus]] among patients with HIV.
|SubCategory=Infectious Disease, Infectious Disease
|AnswerD=Trimethoprim/sulfamethoxazole
|MainCategory=Internal medicine
|AnswerDExp=This is the drug of choice for the prevention of PCP among HIV-positive patients with CD4+ T cell count of <200 cells/µLcells/mm<sup>3</sup>.
|MainCategory=Internal medicine
|SubCategory=Infectious Disease, Infectious Disease
|Prompt=A 23-year-old HIV-positive woman comes to the health center for a checkup. Her CD4 count has been decreasing over the last 5 months, although she remains asymptomatic. Her current exam is normal but her CD4 count is returned as 192 mm3. What prophylactic medication is appropriate at this time?
|Explanation=Since this patient's CD4 count has dropped to less than 200 mm3, it's appropriate to provide prophylaxis against Pneumocystes carini with TMP/SMX.
|AnswerA=Isoniazid and rifampin.
|AnswerB=Penicillin G.
|AnswerC=Valacyclovir.
|AnswerD=Trimethoprim/sulfamethoxazole (Bactrim).
|AnswerE=Ketoconazole.
|AnswerE=Ketoconazole.
|AnswerEExp=This is effective in treating opportunistic fungal infections e.g., [[candidiasis]], among HIV-positive patients.
|EducationalObjectives=PCP is an opportunistic infection commom among HIV-positive patients with a CD4+ T cell count of <200 cells/mm<sup>3</sup>.  The drug of choice is TMP-SMX.
|References= "The risk of Pneumocystis carinii pneumonia among men infected with human immunodeficiency virus type 1. Multicenter AIDS Cohort Study Group". N. Engl. J. Med. 322 (3): 161–5. doi:10.1056/NEJM199001183220304
"Risk factors for primary Pneumocystis carinii pneumonia in human immunodeficiency virus-infected adolescents and adults in the United States: reassessment of indications for chemoprophylaxis". J. Infect. Dis. 178 (4): 1126–32.
http://www.wikidoc.org/index.php/HIV_opportunistic_infection_pneumocystis_pneumonia:_prevention_and_treatment_guidelines#Treatment_of_Disease
|RightAnswer=D
|RightAnswer=D
|WBRKeyword=HIV, HIV opportunistic infections, Pneumocystis carinii prophylaxis
|Approved=No
|Approved=No
|Answer=Isoniazid and rifampin.,Penicillin G.,Valacyclovir.,Ketoconazole.
|Answer=Isoniazid and rifampin.,Penicillin G.,Valacyclovir.,Ketoconazole.
}}
}}

Latest revision as of 23:02, 27 October 2020
Author PageAuthor::Anonymous (Edited by Ayokunle Olubaniyi and Alison Leibowitz)
Exam Type ExamType::USMLE Step 2 CK
Main Category MainCategory::Internal medicine
Sub Category SubCategory::Infectious Disease, SubCategory::Infectious Disease
Prompt [[Prompt::A 23-year-old HIV-positive woman recently started on HAART therapy comes to the health center for a checkup. Her CD4 count has been decreasing over the last 5 months, although she remains asymptomatic. Physical examination is unremarkable but her current CD4 count is 192 cells/mm3.

Which of the following prophylactic medications is most appropriate at this time?]]

Answer A [[AnswerA::Isoniazid and rifampin.]]
Answer A Explanation [[AnswerAExp::These are used in the treatment of tuberculosis.]]
Answer B [[AnswerB::Penicillin G]]
Answer B Explanation AnswerBExp::This is usually used to treat syphilis in HIV-positive patients. It is not used as a prophylactic medication against PCP.
Answer C [[AnswerC::Valacyclovir.]]
Answer C Explanation [[AnswerCExp::Valaciclovir is effective in preventing cytomegalovirus among patients with HIV.]]
Answer D AnswerD::Trimethoprim/sulfamethoxazole
Answer D Explanation [[AnswerDExp::This is the drug of choice for the prevention of PCP among HIV-positive patients with CD4+ T cell count of <200 cells/µLcells/mm3.]]
Answer E AnswerE::Ketoconazole.
Answer E Explanation [[AnswerEExp::This is effective in treating opportunistic fungal infections e.g., candidiasis, among HIV-positive patients.]]
Right Answer RightAnswer::D
Explanation [[Explanation::Pneumocystis pneumonia (PCP) is relatively rare in people with normal immune systems but common among people with weakened immune systems, such as premature or severely malnourished children, the elderly, and especially AIDS patients, in whom it is most commonly observed today. PCP can also develop in patients who are taking immunosuppressive medications (e.g. patients who have undergone solid organ transplantation) and in patients who have undergone bone marrow transplantation.

HIV-infected adults and adolescents, including pregnant women and those on antiretroviral therapy, should receive chemoprophylaxis against PCP if they have a CD4+ count of <200 cells/µL (AI). The drug of choice is trimethoprim/sulfamethoxazole (TMP-SMX).
Educational Objective: PCP is an opportunistic infection commom among HIV-positive patients with a CD4+ T cell count of <200 cells/mm3. The drug of choice is TMP-SMX.
References: "The risk of Pneumocystis carinii pneumonia among men infected with human immunodeficiency virus type 1. Multicenter AIDS Cohort Study Group". N. Engl. J. Med. 322 (3): 161–5. doi:10.1056/NEJM199001183220304

"Risk factors for primary Pneumocystis carinii pneumonia in human immunodeficiency virus-infected adolescents and adults in the United States: reassessment of indications for chemoprophylaxis". J. Infect. Dis. 178 (4): 1126–32.

http://www.wikidoc.org/index.php/HIV_opportunistic_infection_pneumocystis_pneumonia:_prevention_and_treatment_guidelines#Treatment_of_Disease]]

Approved Approved::No
Keyword WBRKeyword::HIV, WBRKeyword::HIV opportunistic infections, WBRKeyword::Pneumocystis carinii prophylaxis
Linked Question Linked::
Order in Linked Questions LinkedOrder::
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