Hiv web study

A. Dermatologic manifestations

HERPES SIMPLEX VIRUS

1. HSV infection Mana yg benar ttg HSV infeksi pd HIV pasien?

(a) When performing a fluorescent antibody (FA) and culture for HSV, scraping the base of the lesion will provide a lower
yield than obtaining exudative fluid.

Because HSV is an intracellular virus, the yield of either fluorescent antibody (FA) or culture is significantly greater if a
substantial number of cells are obtained when collecting the specimen. Direct HSV antigen testing with either FA, EIA, or
PCR can provide rapid results (within 24 hours). Culture for HSV is very sensitive and virus will typically grow in 1 to 4 days.

Saat mlkkukan fluoresen antibodi dan kultur viru HS, menggores dasar lesi akan memberikan hasil lebih rendah drpd
diperoleh dri cairan eksudat  SALAH

 Hsv adalah virus intra sel, dan hasilnya dg FA maupun kultur scr signifikan lebih besar jika sejumlah besar sel
diperoleh pas ngambil spesimen.

(b) terapi yg paling tepat adalah valgansiklovir  SALAH

 Valgansiklovir itu ARV yg aktivitasnya bagus thd CMV dan sedang thd HSV. Gansiklovir itu bkn obat yg disarankan
utk HV infeksi

(c) Diagnosis kronik (>4 bulan) ulser herpes simpleks itu termasuk AIDS-defining conditions, tanpa memperhatian berapa
CD4 count nya  BENAR

 Menurut CDC

(d) Oral prendisone di rekomendasikan sbg terapi tambahan utk pasien dengan kronik ulser HSV infeksi  SALAH

 Ga ada data yg mendukung

Therapy for Initial or Recurrent Infection

 Menurut AIDSinfo pengobatan yg disarankan untuk genital HSV (initial or recurrent) tdr dr 5-14 hari of valacyclovir
(Valtrex), famciclovir (Famvir), or acyclovir (Zovirax); pengobatanya sama utk orolabial lesions, TAPI for a 5 to 10
day course .
 Utk pasien dg lesi HSV mucocutaneous parah direkomendasikan pake intravenous acyclovir utk inisial terapi,
dilanjutkan oral terapi saat lesi nya sdh mulai membaik.
 In general, these patient should receive therapy for HSV until the lesions have completely healed.

Suppressive Therapy

Pasien yg sering kambuh atau parah kambuh infeksi HSV di anggap suppressive therapy dengan valacyclovir, famciclovir, or
acyclovir
2. Acylovir-Resistant HSV infection

Which one of the following would be the most effective therapy at this point for presumptive acyclovir-resistant herpes
simplex virus infection?

(a) Acyclovir (Zovirax)

10 mg/kg IV q8h  SALAH

Pake asiklovir dosis yg sangat tinggi gabakal bisa menolak/mengesampingkan asiklovir resisten, thus i.v asiklovir bukan
pilihan yg bagus

(b) Famciclovir (Famvir) 500 mg PO tid.  SALAH

 kebanyakan asiklovir-resisten HSV infeksi itu hasil dari penurunan produksi enzim thymidine kinase virus. Nah,
Famciclovir, itu prodrug dari penciclovir dan aktivasi penciclovir itu tergantung dari thymidine kinase virus. Jadi, resistensi
asiklovir secara umum juga menyebabkan resistensi famciclovir.

(c) Foscarnet (Foscavir) 40 mg/kg IV q8h  BENAR

 dia ga perlu aktivasi oleh enzim thymidine kinase virus, thus aktivitasnya tetap thd HSV mau enzim tsb ada atau berubah

(d) Valacyclovir (Valtrex) 1000 mg PO tid  SALAH

Valacyclovir (Valtrex) is an acyclovir prodrug . it would not likely override the acyclovir resistance.

Recommended Therapy

Obat2 yg butuh aktivasi inisial oleh enzim timidin kinase seperti asiklovir, famsiklovir dan valacyclovir biasanya hasilnya ga
efektif terhadap virus herpes yg produksi enzim kinase ny terganggu. Gansiklovir dan valgansiklovir jg butuh aktivasi dg
enzim kinase yg mirip, dia juga g efektif buat virus yg resisten. Karena foscarnet ga butuh aktivasi oleh enzim tsb, jd dia ttp
bisa aktif melawan HSV.

Guidelines 2013 nyaranin pake 1st line foscarnet durasi 21-28 hari

Alternative Therapies

Cidofovir (Vistide). Krn cidofovir ga butuh aktivasi oleh enzim virus tsb, jd scr teori dia seharusnya aktif thd virus resisten
asiklovir.

Guidelines 2013 utk OI mencantumkan terapi topikal pake trifluridine, cidofovir, and imiquimod dan juga i.v cidofovir sbg
alternatif terapi utk virus HSV resisten asiklovir dg duras 21-28 hari
KAPOSI’S SARCOMA

A 32-year-old HIV-infected man presents to clinic having noticed reddish-brown nodular lesions on his skin. His risk factor
for acquisition of HIV is having sex with other men, his CD4 count is 230 cells/mm3, and he has never taken antiretroviral
agents. A biopsy confirms Kaposi's sarcoma.

Which one of the following is TRUE regarding Kaposi's sarcoma?

(a) pd bbrp pasien, penggunaan ART saja bisa menyebabkan perbaikan yg signifikan pada lesi Kaposi’s sarcoma 
Correct  Some patients, however, do not have any improvement in Kaposi's sarcoma lesions with antiretroviral therapy.

(b) Human herpes virus type 6 (HHV-6) is the causative agent of Kaposi's sarcoma.  SALAH
 HHV-8 !! penyebab KSHV (Kaposi's sarcoma-associated herpesvirus )

(c) Although Kaposi's sarcoma can be serious, it is not an AIDS-defining illness.  SALAH
 IT IS AN AIDS-DEFINING ILLNESS. Buat org yg terinfeksi hiv, jenis kaposis sarcoma apapun mau itu cutaneous atau visceral
itu AIDS defining illness

(d) For patients with visceral Kaposi's sarcoma, bleomycin combined with vincristine is the treatment of choice.  SALAH
 Visceral Kaposi's sarcoma typically requires systemic cytotoxic chemotherapy.
 Pegylated liposomal doxorubicin (Doxil, Dox-SL, Evacet, and LipoDox) and liposomal doxorubicin
(Caelyx and Myocet) are now established as the preferred therapies.
 pegylated liposomal doxorubicin LEBIH memiliki respon lebih baik dan efek samping lebih dikit drpd bleomycin plus
vincristine

General Approach to Treatment Immunotherapy

- Tergantung lesinya
- Semua pasien kaposis sarcoma harus pake ART
yg poten dan fully suppressive
Antiretroviral Therapy
Pake ART yg poten
Local Treatment
termasuk operasi excisional. Cryotherapy cairan
nitrogen, terapi yg diaplikasikan scr topikal
(retinoic acid/ alitretinoin 0.1% gel), kemoterapi
intralesi (pake vinblastine  buat lesi lbh
besar dr 1 cm), terapi fotodinamik, radiasi atau
kombinasinya.
Systemic Cytotoxic Chemotherapy
Buat pasien yg tipe visceral, lebih dari 20 lesi,
masalah limfatik. For patients with advanced
Kaposi's sarcoma, the liposomal anthracyclines—
pegylated liposomal doxorubicin(Doxil, Dox-SL,
Evacet, and LipoDox) or liposomal doxorubicin
(Caelyx, Myocet)—are now established as the
preferred therapy.
interferon alfa (Roferon or Intron-A) was commonly
used to treat advanced Kaposi's sarcoma.
Responses to interferon preparations are better in
patients who have a CD4 count greater than 200
cells/mm3 and those with asymptomatic HIV
disease.[39] An AIDS Clinical Trials Group study
that investigated didanosine (Videx) combined with
either low dose (1 million units/day) or high dose
(10 million units/day) interferon alpha, reported
that patients in the low-dose group had a response
rate of 40% versus 56% in the high-dose group.
Antiviral Medications and Molecular
Targeted Agents
Theoretically, antiviral agents are more likely to
have benefit as preventive therapy, but this
strategy has not been widely used, primarily
because of medication toxicity. Specific molecular
targeted agents under investigation for
Kaposi's sarcoma[12] include
angiogenesis inhibitors[43,44] tyrosine kinase
inhibitors[45], and matrix
metalloproteinase inhibitors.[46] These molecular
targeted therapies are considered investigational
for the use of treatment of Kaposi's sarcoma.
Varicella Zoster Virus

Which of the following statements is TRUE regarding varicella zoster virus (VZV) infection in HIV-infected patients?

(a) A positive Tzanck stain adalah diagnostic untuk VZV infection dan jg mengatur penyebab lesi kulit vesicular lanya seperti
infeksi HSV  SALAH
 The finding of multinucleated giant cells on Tzanck (Giemsa) staining is neither sensitive nor specific for diagnosing viral
vesicular lesions.
 Metode ini ga sensitif maupun spesifik utk mendiagnosis lesi virus. Lebih bagus pake fluorescent

(b) terapi utama untuk herpes zoster pada pasien terinfeksi HIV terdiri dari acyclovir (Zovirax), valacyclovir (Valtrex), or
famciclovir (Famvir)  BENAR
 The duration of therapy is typically 7 to 10 days, but longer courses should be considered if the lesions are slow to
resolve. Corticosteroids are not recommended in this setting.

(c) terapi utama untuk herpes zoster pada pasien terinfeksi HIV terdiri dari oral valganciclovir (Valcyte)  SALAH
Neither intravenous ganciclovir (Valcyte) nor oral valganciclovir (Valcyte) are recommended to treat herpes zoster.

(d) The incidence of herpes zoster in HIV-infected individuals is the same as age-matched HIV-negative persons.  SALAH
 pada pasien hiv hampir 10x lebih besar risk nya drpd org dg imunokompeten

Therapy for Varicella and Zoster Infections
All patients with an acute episode of varicella or zoster
should promptly receive antiviral treatment.[4]
Therapy for Varicella
- Pasien terinfeksi HIV dg koinfeksi varisella yg
sederhana bisa diobati dg oral ART.
- In contrast, HIV-infected persons with complicated
primary varicella infection, including involvement of
visceral organs, retina, or the central nervous system,
should receive treatment with intravenous acyclovir
and undergo hospitalization for observation. if the
patient responds well to intravenous acyclovir, they
can typically switch to oral antiviral therapy to finish
their treatment course.
Therapy for Zoster
 The recommended antiviral treatment options
for localized dermatomal zoster in HIV-infected
persons consist of valacyclovir (Valtrex), famciclovir
(Famvir), or acyclovir (Zovirax) dg dosis lebih tinggi
drpd treatment HSV yg sederhana.
 globulin (VZIG) should be administered as soon possible
Accordingly, the use of corticosteroids as part of the
treatment for herpes zoster in HIV-infected persons is
not recommended.
 setting of cancer therapy have documented successful
Treating acute zoster-associated neuropathic pain or
post-herpetic neuralgia is an important component of
the management of patients with VZV infection.
Opioids, tricyclic antidepressants, gabapentin
(Neurontin), and topical lidocaine or capsacin (Zostrix)
have all been shown to be effective in reducing pain
associated with these conditions
Therapy for Acyclovir-Resistant VZV
resistance should be suspected in patients who have
lesions that do not improve within 10 days of starting
antiviral therapy. One report described 18 HIV-infected
patients with advanced immunosuppression and
acyclovir-resistant VZV-related skin lesions that failed to
heal despite treatment with acyclovir.,most of these
patients had an excellent respond to treatment with
foscarnet (Foscavir). Based on this report, as well as in
vitro data, foscarnet is the recommended drug of choice
for acyclovir-resistant VZV.
Post Exposure Prophylaxis with Varicella Zoster Immune
Globulin
In the rare instance when an HIV-infected person who is
non-immune to VZV has significant exposure to a patient
with active varicella or zoster, varicella zoster immune
after the exposure, but within 10 days. case series from
adults and children with immunosuppression in the
use of valacyclovir for the prevention of varicella.
Varicella vaccine should be deferred for 5 months after
receipt of VZIG and for at least 72 hours after the last Prevention of Varicella and Prevention of Zoster
dose of an antiviral regimen used for postexposure Pake vaksin
prophylaxis.
molluscum contagiosum

Which one of the following statements is TRUE regarding molluscum contagiosum in HIV-infected persons?

(a) diagnosis molluscum contagiosum pada pasien ini mungkin salah karena penyakit ini hampir g pernah ada di muka org
hiv  SALAH

 Molluscum contagiosum most frequently involves the face, neck, and genital tract in HIV-infected persons. In contrast,
immune competent HIV-negative persons most often have lesions on the trunk, extremities, or groin.

(b) Molluscum contagiosum is caused by human papillomavirus (HPV) type 6  SALAH

 Molluscum contagiosum is caused by a DNA poxvirus, not HPV. Warts, which can clinically menyerupai molluscum, result
from infection with HPV.

(c) Although molluscum contagiosum can result in membuat skin lesions in HIV-infected persons with advanced immune
suppression, these individuals do not develop systemic complications from molluscum  BENAR

(d) Recent data have shown that valacyclovir (Valtrex) is a highly effective treatment for molluscum in HIV-infected persons
 SALAH

 The drug cidofovir (Vistide) is the only antiviral compound convincingly shown to have direct activity against the poxvirus
that causes molluscum contagiosum. Treatment with antiretroviral medications often causes an improvement in
molluscum, but this presumably occurs as a result of enhanced immune function, not direct antiviral activity.