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Old 10-30-2012
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Arrow Gyrus Daily Questions; Internal Medicine #60

An HIV - positive woman with 22 CD4 cells/ul is admitted with Pcp and is treated successfully with TMP/SMX and azithromycin are started.She is then started on antiretroviral medication and her CD4 rises to 420 cells for the last 6 months.

What is the most appropraiate next step in the management of thus patient ?

A. Stop TMP/SMX.
B. Stop both TMP/SMX and azithromycin.
c. Stop all medication and observe.
d. Stop all medication if the PPCR- RNA viral load is undectectable
e. Continue all the medications.
f. Stop the azithromycin
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Should b B. You stop TMP/SMX and Azithro and carry on with anti-retroviral meds
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Originally Posted by cingulate.gyrus View Post
An HIV - positive woman with 22 CD4 cells/ul is admitted with Pcp and is treated successfully with TMP/SMX and azithromycin are started.She is then started on antiretroviral medication and her CD4 rises to 420 cells for the last 6 months.

What is the most appropraiate next step in the management of thus patient ?

A. Stop TMP/SMX.
B. Stop both TMP/SMX and azithromycin.
c. Stop all medication and observe.
d. Stop all medication if the PPCR- RNA viral load is undectectable
e. Continue all the medications.
f. Stop the azithromycin
Stop the prophylactic medication.

This is also a good time to give the only live vaccine that has to be given because the benefits outweigh the risks.

That vaccine is MMR, obviously you do this if the patient hasnt been vaccinated.

Another 2 vaccines that should be given in case the patient didnt receive it are influenza and pneumococcus

I mentions this because the question can be twisted and these things can be asked
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I think you can also give varicella vaccine if the CD is above 200.
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Originally Posted by Novobiocin View Post
I think you can also give varicella vaccine if the CD is above 200.
I read somewhere that as well that but I answer that in the qbank and got it wrong, apparently the only 2 live vaccines that are approved for exam purposes are MMR and Yellow Fever vaccines.
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Originally Posted by XpaezX View Post
I read somewhere that as well that but I answer that in the qbank and got it wrong, apparently the only 2 live vaccines that are approved for exam purposes are MMR and Yellow Fever vaccines.
Check UW QID 4478
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My uworld subscription died
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Quote:
Originally Posted by XpaezX View Post
My uworld subscription died
You can renew it if it has been less than 48 hours or get a new subscription for 2 weeks ans ask them to restore the historical data. I find the search function of UW very useful during the review.
Anyway it's here and here.

Quote:
Inactivated vaccines are generally acceptable and live vaccines are generally avoided in persons with HIV infection [4]. However, some live vaccines (eg, varicella) are recommended in HIV-infected patients with CD4 cell counts >200 cells/microL.
Quote:
However, weighing the risk for severe disease from wild VZV and potential benefit of vaccination, vaccination may be considered (2 doses, administered 3 months apart) for HIV-infected persons with CD4+T-lymphocytes count >200 cells/µL in these age groups. If vaccination of HIV-infected persons results in clinical disease, the use of acyclovir might modify the severity of disease.
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Wow thAnk you man, now i remember where i saw it haha
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Thank you all especially Novobiocin for the discussion you peoples Rock...

Answer is B. Stop both TMP/SMX and azithrocycin.

If CD 4 count is maintained above 200/ul for several months, prophylactic TMP/SMX can be stopped. Azithromycin is used as prophylaxis for atypical mycobacteria and is used when CD4 count count is below 50/ul

Antiretroviral cannot be stopped as CD 4 count is maintained by it.

Use of prophylactic medication is based on CD4 count not on viral load.

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