A 35-year-old woman who was recently diagnosed with HIV comes to the office for evaluation after moving to New York City from Tucson, Arizona. She began taking highly active antiretroviral therapy 9 months ago and has been compliant with the regimen. She also takes trimethoprim/sulfamethoxazole for Pneumocystis pneumonia prophylaxis. The patient reports no symptoms except for occasional nausea. Her CD4 count 3 months ago was 210/mm³. She also has a history of asthma, which is stable with inhaled beclomethasone therapy.
Vital signs are within normal limits. Examination shows no abnormalities.
Laboratory results are as follows:
The patient's viral load is undetectable.
Chest x-ray shows no acute disease.
Which of the following is the best next step in management of this patient?

Question

A 35-year-old woman who was recently diagnosed with HIV comes to the office for evaluation after moving to New York City from Tucson, Arizona. She began taking highly active antiretroviral therapy 9 months ago and has been compliant with the regimen. She also takes trimethoprim/sulfamethoxazole for Pneumocystis pneumonia prophylaxis. The patient reports no symptoms except for occasional nausea. Her CD4 count 3 months ago was 210/mm³. She also has a history of asthma, which is stable with inhaled beclomethasone therapy.
Vital signs are within normal limits. Examination shows no abnormalities.
Laboratory results are as follows:

The patient's viral load is undetectable.
Chest x-ray shows no acute disease.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9860_545a_853d_7fb123f0a03c_MD0002_00 Pneumocystis jiroveci pneumonia (PCP) is a common AIDS-defining illness and is a major cause of death in patients with untreated AIDS. Prior to the use of antiretroviral therapy (ART), 70%-80% of patients with AIDS developed PCP, and approximately one-third of these individuals died from the condition. The vast majority of cases occur in patients with CD4 counts <200/mm³. ³ Chemoprophylaxis against PCP is recommended for all patients with HIV who have CD4 counts <200/mm³. Chemoprophylaxis should also be considered in those with higher CD4 counts who develop oropharyngeal candidiasis (indicating susceptibility to opportunistic infections) or have low CD4 count percentage (<14%). Once-daily, double-strength, oral trimethoprim-sulfamethoxazole (TMP-SMX) is the preferred agent. Alternate medications include dapsone, pentamidine, and clindamycin/primaquine. Prophylaxis can be discontinued when ART improves CD4 counts to >200/mm³ for >3 months, as in this patient. Cessation reduces the risk of drug toxicity/interactions and of developing drug- resistant organisms. (Choice A) Azithromycin prophylaxis against Mycobacterium avium complex was previously recommended for patients with AIDS who have CD4 counts <50/mm³ but is no longer recommended given the low risk of MAC among patients taking ART and the lack of differences in MAC disease outcomes between those who did or did not receive MAC prophylaxis. ³ (Choice B) Primary chemoprophylaxis against coccidiomycosis is not recommended for HIV-positive patients. However, patients who live in or travel to endemic regions can be screened for exposure with twice-annual serologic testing. Those who become seropositive and have CD4 counts <250/mm³ are generally given fluconazole prophylaxis if no disease manifestations are present. ³ (Choice D) Beclomethasone has stabilized this patient's asthma, and stopping the drug would likely worsen her condition. This drug has minimal interactions with ART and TMP-SMX. Educational objective: Prophylaxis for Pneumocystis pneumonia is recommended for patients with AIDS who have CD4 counts <200/mm³. Prophylaxis can be safely discontinued in patients on antiretroviral therapy who have CD4 counts >200/mm³ for >3 months. ³ ³ __________ References: Long-term safety of discontinuation of secondary prophylaxis against Pneumocystis pneumonia: prospective multicentre study. (http://www.ncbi.nlm.nih.gov/pubmed/15577626) Pneumocystis jirovecii prophylaxis discontinuation based upon total lymphocyte count in HIV-infected adults treated with antiretroviral therapy. (http://www.ncbi.nlm.nih.gov/pubmed/20606220)

A 35-Year-Old Woman Who Was Recently Diagnosed with HIV Comes