In The Clinic: Management of Newly Diagnosed HIV Infection

As a primary care physician, some of the decisions you make will help shape the course of your patient’s chronic disease (which is also up to 47% of inpatient expenditures!). The American College of Physicians has an excellent series called “In the Clinic.”  Today, we present their guidance for the management of newly diagnosed HIV infections (click the image below to link to the article):

Newly diagnosed HIV

http://annals.org/article.aspx?articleid=1033117

#clinicalpearls: Hepatitis B & D

  • Hepatitis B
    • HBsAg → active infection
    • HBsAb → past infection or vaccination against hepatitis B
    • HBeAg → active replication of the virus
    • AntiHBc IgM → acute infection
    • AntiHBc IgG → chronic infection
    • Chronic, and carrier states will have positive HBsAg and Anti-HBcIgG. How can these two conditions be differentiated?
      • Chronic → Increased LFTs
      • Carrier → Normal LFTs
  • Hepatitis D: requires Hepatitis B infection to be present
    • Anti-HBc IgM + Hepatitis D virus → acute co-infection and will not worsen hepatitis
    • Anti-HBc IgG + Hepatitis D virus → acute super-infection and can cause fulminant hepatitis

Polycythemia Vera

  • General Information
    • Polycythemia
      • Defined as increase in # RBC in the peripheral blood
      • Men Hgb >18.5 or Hct >52
      • Women Hgb > 16/5 or Hct >48
    • Relative polycythemia
      • A decrease in plasma volume that elevates the Hct or Hgb
    • Absolute polycythemia
      • Primary – mutations such as polycythemia vera, idiopathic familial polycythemia, EPO R gene mutations
      • Secondary – chronic hypoxia (high altitude, smoking, cardiac shunts, pulmonary disease, sleep apnea, EPO producing tumors (RCC, HCC, pheo, uterine fibroids), other (use of EPO injection, steroids, blood doping)
  • Symptoms
    • Indicating the hyperviscosity: chest pain, abd pain, HA, change in vision or mentation
    • Indicating polycythemia vera: post bath pruritis, erthromelalgia, gout , arterial or venous thromboses
  • Diagnosis
    • Repeat testing to avoid testing transient increases
    • History and physical considering the prior diagnoses listed, the most common cause of polycythemia is hypoxia 2/2 pulmonary disease
    • Pulse ox and ABG, CBC, UA, LFTs, CXR
    • If etiology is unclear, consider checking EPO and JAKPCV
  • Management
    • Phlebotomy: often to a goal hct below 45 for men or 42 for women.
    • Low dose ASA to reduce thrombotic complications
    • Cytoreductive therapy: i.e. hydroxyurea
    • Other therapies:
      • Interferon
      • Anagrelide (inhibits platelet maturation): PCV with secondary thrombocytosis
      • Erlotinib
      • Selective JAK2 inhibitors are being investigated