DIP Episode 237 - HIV and The USMLE

Okay, welcome. My name is Devon. I'm a resident. This is episode 237 of the Devon intervention podcasts. And in this podcast, I'm going to be talking about HIV and the USM Ls. HIV is a very high-yield topic to know for the US, all the USML exams. So let's just go ahead and jump right into it. So hopefully if you understand what's here, if you would answer any HIV question on step one, step just use the case step three. So each I fear, right, we know it's a retrovirus, right, and we know that for the most party, clubbers are persons immune system, right? And what, you know, when people's immune systems are clubbed, they begin to have all these opportunistic infections, they begin to have all these malignancies. Because believe it or not, your immune system actually reduces the risk of getting cancer, right? That's why you notice people that are immunocompromised, like these post-transplant recipients, you notice that they tend to have these very higher incidents of malignancies, especially like lymphomas and leukemias and things like that. Now, with regards to HIV, I remember that, you know, HIV has a variant and that variant has like an envelope. I remember the envelope has like the GP41 and the GP120 glycoproteins, you know, it kind of has a matrix on the inside, which contains the P17 protein, and then it has a cup set, right, which is has the P24 protein, right?

And they remember it has like two single stranded copies of RNA, you know, plus some kind of like enzymes, like in the core, right? And remember that the glycoproteins on the variants, right? On the variant, like the GP41, GP120, the binds to CD4, and then the binds to one of two receptors. One is called CCR5, the other one is called CXER4, and those things are found on CD4 positive or telomfocytes, right? They use that to fuse and get into cells, right? And then you know, once they get into the cells, because it's RNA can really work very hard with RNA in a human cell, right? So that RNA you convert is a double stranded DNA with a reverse transcriptis, right? That double stranded DNA then gets integrated into the genome by an enzyme known as integrates that causes the HIV. And then when you transcribe that viral DNA, you know, you do all these transcription, translation, and then you make new variants that then go on to infect other cells. And HIV or it is transmitted whenever you have anybody fluids that are moving around, right? So like, you know, like it's translated through like C-men, it can be transmitted through, like, you know, like from mom to baby, right? It can be transmitted from like contaminated blood products, like sharp, like sharp singeries, needle sticking juries, right? So those are all different ways people can get HIV, right?

And remember, if you are homozygos for like, if you have like this mutation called the A32 mutation, if you have homozygos for that mutation, with CCR, it's like, it's a CCR5 mutation, but it's called specifically an A32 mutation. If you have homozygos for that mutation, you are pretty much resistant to getting HIV, but if you're ahead of your rezygos, you tend to have like a slower course of disease. That's a high-o thing to know for the for the USMLA exams, right? And again, one of the most high fidelity ways of getting HIV through contaminated blood products, I mean, the probability is almost 95%. As you mean you don't get treated, you don't get any post exposure, perphylaxis, or anything of that sort, right? So it's just one of those things, you know, you kind of want to be careful about, especially if you're at healthcare, you're a healthcare worker. And basically, the way HIV pretty much works, right? So, you know, when people get like the infection initially, they have this thing called the Accuracy Viral Syndrome, right? So, you know, they'll have like a flu-like illness, they'll have like fevers, mastiffar angitis, they'll have like cervical lymphatic anapathy, they'll have like a rash, they can have like oral ulcers, they lose a ton of weight, and usually last for about two to six weeks after they've been exposed to the virus, right? And typically those people also have like hematologic problems, right?

So, like the applied layer count will be low, the away blood cell count will be low. And when people have this problem, they have a very, very high risk of transmission, right? And then after that, you know, they kind of go into the latent fees, and in the latent fees, right? The HIV is like replicating through many of those CD4 positive T cells. And pretty much, you lose about a hundred of your CD4 positive T cells every year, right? So, this asymptomatic, like this latent stage kind of goes on for about ten years, right? And by this age, if people go on for like ten, this ten-year period and they don't get treated, right? They essentially begin to have like, you know, like advanced HIV, basically they've gotten like to the standpoint of AIDS, right? And the thing is, what is the definition of AIDS? Because HIV and AIDS are not the same thing, right? Basically, AIDS means a person is HIV positive, and they have some AIDS-defining illness, right? So, it can be like an opportunistic infection, like the Mosisis-Drovetse, or it can be them having like a Sova-Joke kind of diocese, so they have CMV, or they have Mac, or they have TB, or they have Toxyl, right? It can even be on my legacy. So, they're HIV positive, and let's see, for example, they have like cervical cancer, right? Or they have Capposis or coma, right? Those things are telling that if this person's got AIDS, right?

I mean, they used to use this criteria of like, OCD4 less than 200, but I mean, like in this age of antiretroviral therapy, it's not really like a huge issue, anymore, right? And in general, right? Again, you want to remember some key things that can happen at certain CD4 markers. These are just rough values, but just things to keep in mind. But if your CD4 positive T-cell count is less than 500, some things that can happen is, you know, those people they can have, you know, they can have like, they can have like the Sova-Joke kind of diocese, they can get lymphomas, if it's less than 200, obviously, Mosisis-Drovetse is the only one I think about. They can also again get throsh, they can get all these problems, right? Like Cryptococcus, Neopharmus with the meningitis, or if you live in a susceptible area like Arizona, you could get like, oxiditis, amethyst, or if you live in a susceptible area like Kentucky or Ohio, Indiana, you can get like, Houston plus Mosis, right? And then if your CD4 count drops you lower 100, you want to begin to think about things like PML, right? Like progressive multifocal look and stuff, a lopathy, right? With the GC virus, remember, people can also get that from a T-kin that I'll use you up for MS, right?

And then also like, Toxo, remember, multiple ring, again, Hansen lesions, although it could be single on an in-be-me, if they want to mess with your head, multiple ring, enhancing lesions on imaging, the brain of HIV patients, you know, think about Toxo, Toxo plasma, Gondii. And then if you're less than 50, right? You want to think about things like CMV, like CMV can cause like, right? Nidus, like visual disturbances in a HIV patient, I want to think about CMV, you know, Mac, right? Which are prophyluxicins with a zythromycent, right? And they can also get like, this thing called a bacillary angiomatosis, right? So it's like, they have like, this 75, like, Martinle, right? And then they can also get primary CNS lymphoma, again, that usually happens when they are less than, when they're at a city for count of less than, less than 50, right? And again, don't forget these key things, it's ready for those taking step one, P24 is the Capsid protein, okay? GP41 is the protein that's used for fusion and entry. And then GP120 is what you use to essentially attach to the host, to the host T cell. So now, how do you make the diagnosis, right? So the thing is, on NVM exams, you can pick one of two answers to screen, right? So one answer you can pick, which is, again, still pretty common in exams is to do the ELISA, right? That's what's called the third generation antibody test. And you know, the sensitivity is like 99.5%. So it's not terrible, it's pretty good, right?

But in this day and each, you know, they do this thing called the fourth generation test. The fourth generation test is basically the ELISA that was done before. But in addition to that, you are also detecting the P24 antigen, right? So you're detecting the P24 antigen and you're doing an ELISA to, you know, like essentially the HIV antibody test, right? Again, it's very sensitive, like the sensitivity and specificity of that test, the fourth generation test, like 100%. So it's pretty good, right? But after you've screened, right, you need to confirm. And the way you confirm is you do a Western blood, right? You do a Western blood. Basically, the Western blood helps you detect like, you know, at least two antibodies against like two different HIV proteins, like GP41 or P24 or GP120, GP160. Again, the specificity of this confirmatory test is like essentially 100% right? So it's pretty good. It's pretty good, right? And in general, right? So how do you take care of people that have a HIV? Well, the thing you'd want to do is, yeah, so I'll say like some high yield things you want to keep at the back of your mind is for these people, right? You want to do like, obviously, want to get their viral load. You want to figure out what's going on like HIV RNA levels, right? You want to check them for B50, HLEB57 on NB Ns. Remember, HLEB57 has an association with like a Baccavere hypersensitivity. So you want to check them for that.

If you're thinking, this will be more of like a step one question or step three question. If you're thinking of like giving them like a CCR5 inhibitor, right? As one of their pharmacologic therapies, then you know, it's probably prudent to see if they have like that A32 mutation with CCR5 because obviously, they will not work in those people, right? And then you want to get a PPD, right? Don't forget five millimeters of intuition that's positive in a patient that's got a HIV, right? And you know, you just want to again, like also like after they've started like anti-retroviral therapy, you want to get like their regular lipid profiles, their glucose because many of those are anti-retroviral therapy, whatever things, right? Those things can definitely cause them, can definitely cause what is it called? They can cause like metabolic syndrome and all that badness. I mean, these days for a person that's treated for HIV, the thing that kills them these days is more like cardiovascular disease than anything else. That's a higher point you want to know, for exams, right? And then some key higher things you want to keep in mind with regards to HIV, they love to ask about these like vaccinations and preventive medicine strategies in these people. These folks, you actually want to make sure that they get like the influenza vaccine every year. That's high your to know. You want to make sure that they get the PPSV23 and the Mokoko vaccine every five years, right?

If they are not immune against a HIV, you want to give them the HIV vaccine possible. And you know, you also want to give them the HPV vaccine, especially if they are young, right? And then people that have HIV, they get annual pap smears, right? It's not like, oh, between 21 and 30, I do it every three years or if you're over 30, you can do the every three year pap smears or the PPSV, HPV code test every five years, which is preferred. In HIV patients, you do pap smears every year. That's a very high your thing to know, for exams, right? So, and one of the weird things that occasionally your friends at the MBME throw on exams is they want you to know like some prognostic factors, right? So the thing is a present CD4 count essentially like tells you is a prognosis is the key is the most important prognostic factor for like the progress, like the stage of their disease or the progression of their disease. And then the viral load deals with the rate at which their disease is progressive, right? So like CD4 count tells you what stage they are at. And then to know like the rate at which the disease is progressing, the viral load will help you, the viral load will help you with that. And remember, right, if you're an infant of a HIV mom, right? You know, those infants are going to have a lysa test, right? You're going to have a lysa test because remember, IgG antibodies, anti-HIV, IgG antibodies across the placenta, get into the fetus, right?

So typically for kids, for newborns, if you want to like, if you're wearing like, did these newborns get whatever from mom, you want to go ahead and do a HIV RNA, under those circumstances, right? And again, don't forget your prophylaxis, right? If CD4 less than 250, if you live in a, you know, like a toxic area, like I don't know, like Arizona, Nevada, California, New Mexico, right? If your CD4 count is less than 250, when you live in a susceptible area, you get it your connozol to prophylaxis against oxygen, mycosis. If you have a CD4 less than 200, right, you get prophylaxis against the pneumocystis, you're a vet, see? Typically you use a trimitroprimsulfum ethoxazone, or you can use the absorption on MBM exams, right? And then toxoplasma congi, right? Like, you know, sorry, 150, CD4 less than 150, if you live in a susceptible area, Kentucky or Ohio, Indiana, you want to prophylaxis against a histoplasma capsule atom with itchoconazole, same thing you use for, for coxidium, mycosis, right? And then if the CD4 count is less than 100, right? Again, you want to prophylaxis against toxoplasma congi, right? Again, you do trimitroprimsulfum ethoxazole. And obviously we have TB, right? If it's latent TB, right? You do like, I sonyize it for nine months plus B6, or you can give them right fanping daily for four months, right? Or you can give them this new regimen called, it's like refa pentin plus isonyize it plus D6. You do that daily for essentially three months, right?

Those are the three different regimens for TB, for latent TB, one in MBM exams. Obviously if it's active TB, you're going to use the right regimen, right? And then mac, right? That's a CD4 count less than 50. You're going to use the zythromycin, right? You're going to use the zythromycin. So again, those are all things to know. Though the guidelines don't kind of change a lot, but that's what you should remember for your exam, at least for the next couple of months, probably a few years actually. And the thing is, one weird thing you see on the test is if a person has HIV, right? The thing is, you know, and you know, you start on an anterior trivarial therapy and the CD4 count starts rising, you need to actually continue that those prophylactic drugs they wear on for at least six months while they're on anterior trivarial therapy, right? So basically, they start on HAART and the CD4 count goes up, right? To like standard, it's above like the threshold where you started in a sheet in like those prophylactic antibiotics. They need to have that good CD4 count number for six months before you discontinue the prophylaxis. That's very important to actually, that's actually very high yield out to know. That's very high yield to. And then, one thing you want to keep in mind, again, this may be like one of these like questions that people see on exams and pretty much no one gets it, right? But there's this thing called Exposure Prophylaxis, right? That's beginning to become popular.

You can basically use like the combination of like 10 off of here and M3 Cidabin and it has been found in studies to actually decrease the risk of transmission of HIV. Yeah, so that's just guess a factor that I want to, a factor that I want to throw in there, right? So how do we treat HIV, right? HIV, you know, use a bunch of drugs, but basically the big thing when you're members, you want to give those people two NRT Is and then essentially one drug from another class, two NRT Is and one drug from another class, right? And again, the thing is you kind of want to know, you kind of want to know some high yield side effects with these drugs, right? So like, you know, like your NRT Is, right? Those are these are drugs like M3 Cidabin, Lamyviodin, 10 off of here, Zaidouviodin, Abakavir. What are some key things you want to keep in mind? You know, you want to remember Lactica Cidosis. Lactica Cidosis is probably the big side effect of these drugs, right? And for the most part, these drugs are toxic to the mitochondria, right? And so if you're a mitochondria, it doesn't work. No, you're going to be relying very heavily on glycolysis, right? That's kind of like a similar pathophysiology behind the problems. The Lactica Cidosis that accompanies many of these mitochondria or the solders, right? So, you know, they'll have like a profound Lactica Cidosis. These people can have like a lipodistrophy, right? That's something that's pretty common.

One thing I think you should maybe keep in fact, I'll talk about this later, but really I'll say the big thing when I remember these drugs, when I remember Lactica Cidosis. And again, they are NRT Is, right? So they're basically inhibitor reverse transcripties, right? They are like competitive inhibitors of reverse transcripties. So you can already begin to imagine how they can make like a micolismate in question of that on an NV Me exam, right? So those are just things you want to keep at the back of your mind. And then the NNRT Is, right? These drugs, you know, they're drugs like, and oh, don't forget a Bacchiavere again. Check HLAB57. It's actually a fairly common HLB people. So you kind of want to check that. Another weird thing they love to test is like before you start Bactram, Bactram Prophylaxis on folks like TMPSMX, you want to kind of make sure that those people, you want to make sure that those people don't have G6 PD deficiency, right? So you probably want to test them for it, especially like if it's a guy, right? Because remember, G6 PD deficiency, if a non-stakely is a ex-ling excessive inheritance, right? So you know, be it a boy on a test. Okay. And then don't forget that those, I mean, TMPSMX can use oxidative stress, right? So it can cause methemoglobinemia on an NV Me exam, right? So you want to give methylene blood, obviously, on those circumstances. So they tend to do that methemoglobinemia business with malaria drugs on NV Me, right?

So in an RTI, you know, they all end in like verdene or P, right? So like de laverdeen, effavirens, nevierapine, these are non-nucleuside reverse transcripties inhibitors, right? So they are non-competitive inhibitors, right? Of our reverse transcripties. So again, you can already begin to imagine a mechalism in 10 question from this about like how, oh, these ones will kill your VMAX, but they won't change your key M stuff like that, right? And these drugs, the big thing you want to remember is, effavirens is a teradogen, right? So don't give it to a pregnant woman. And remember that effavirens, right? Causes VVD, dreams. It's like neurotoxic, right? Those are all things they can throw on NV Me exams. And then don't forget your produce inhibitors. They all end in a veer, right? So at a zana veer, they run a veer, return a veer, they'll feed a veer, all that stuff. Basically, these drugs inhibit the, like after you've transcribed and translated the viral genome, right? You need produce to help you kind of chop things up into like nice polypeptize that you can stock into new variants, right? So, basically like the enzyme that does that is produce, so you can hear produce, right? So it basically prevents the maturation of the infectious variants, right? The big thing you want to remember, these things are like, they're cling to film is metabolic syndrome, lipodystrophy, right? So like boffalo-hon behind the neck. Don't forget Indina veer can cause kidney stones.

This is like florida hypo to, for example, Indina veer causes kidney stones. And there is an NRTI, if you forgot to talk about the actually 12 of them, there's like Stavidin and Dydanosine. Those drugs have a very powerful association with pancreatitis. That's very high you to know, for exams as well, right? And they know, forget produce inhibitors. They also awesome, awesome, awesome inhibitors of sediment B450, right? That's florida high you to know, for exams. And then you know, we know, we have like the integrates inhibitors, the all-end in gravere, the rotegravere, rotegravere, elvitegravere. These drugs are relatively clean in inhibiting degrees so that the double stranded DNA you've met through reverse transcripts, these cannot integrate into the viral genome. And then you know, we have like the fusion inhibitor, we have like emphuvertide, you know, it binds to, it basically inhibits the fusion of the viruses with T, of the virus with T cells because it inhibits GP41, right? The site effects a one and worry about that on an NBME. And then we have maravirac, right? Maravirac is a CCR5 blocker, right? Basically again, it prevents the virus from entering, right? So remember, in fuvertide inhibits viral fusion, and then maravirac, right? Prevent viral entry. Recognize those words on NBME exams, the site effects of those out and worry too much about those, right? So those are high-o things to keep in mind.

Okay, now, one of the things I would say is, right, so don't forget, right? Like if you see meningitis in a HIV patient, you want to think about a crypto-cocostial formance, right? Obviously crypto, you're going to give, you're going to make the diagnosis with like India, inxthene of the CSF where you can do like the latex particle agglotnation assay, right? And you treat them with flu cytosine and amphotaresine B. And then after they recover, right? You give them flu connoisseur for like 12 months to reduce the risk of recurrence. If you see that in a HIV patient, right? Obviously, you want to give them a, like, a zoxanide or paromomysine, right? Because you're thinking, hopefully, about a crypto-spiridium problem, right? Remember, those acid fast ulcers in the stool? So for those folks, you know, you want to treat them pretty aggressively. If you see like eye problems, especially again, the person that has like very low CD4 counts, right? You're thinking about CNB right now, you know, you give them gun cyclovera, let's assume the gun cyclovera doesn't work because, you know, they may have like a UL-97 kinase mutation on the test. Then, you know, you want to put those people on first-carnect, which is that pyrophosphita analogue. And don't forget that gun cyclovera is a one-osin analogue, right? It's just one of those rare things. They love to test one example, right? So, and what else I want to say about HIV?

Again, don't forget the 5 millimeter intuition caught off for, for TB. And just trying to think. I feel like I've kind of hit all the very high yield points for HIV. Pretty much talked about pretty much anything, they can, anything they can test on that. So I think I'm going to go ahead and stop here. And as I do at the end of every podcast, I guess the first thing I'll say is that there's this step 2 CK course. It's 10, it's 10 hours, right? All in one day, you basically run the high yields of all the specialties in one day. It's on the 30th of this month, 6 to 10 AM Pacific time, 12 to 4 PM Pacific time, and then 6 to 8 PM Pacific time. Just reach out to me. It will be heard over Zoom. I'm just limiting it to 20 people. It will be heard over Zoom. So it's something you're interested in just reach out to me. Once you make payment through Venmo, I'll then go ahead and add it to the list of people registered for the course. And then I'll offer tutoring for many exams, right? Step 1, step 2 CK, step 2 CS, step 3. Basically, one on one tutoring, pre-clinical medical exams, 30-ish-off exams. So if that's something you're interested in, just reach out to me. And I also do like longitudinal tutoring where if you're studying off-med school or studying off-thirty years, studying off-second year, I'll tutor you for your block exams, or at the same time I'm tutoring for the USMM Es. I've done it with tons of people, very successful with that.

And then also for these booster courses, again, it's one on one, 20 hours for step 1, step 2 CK, step 3. And again, done it with tons of people. Basically, again, we review the high yields, one on one fashion, rapid fire, questioning. And again, many people have had awesome scoring quizzes with the booster course. And then if you're medicine and planning to residency, so like an era's application, or like a college's plan to med school, so like an Amcass application, offer like coaching, with like, writing personal statements, editing applications, doing more interviews in many specialties. If you have like a tricky application, like, like I should have 10 years ago, or low scores, or no research, or you know, just weird stuff in your application. Again, I've worked with people that have had many of these problems, and most of the people I've worked with have much of their first choices. So if that's something you're interested in, just reach out to me, and I'll be happy to kind of point you in the right direction. And you know, please, if you have like a medicine, or like an I.M. or, so like an internal medicine, or a PEEZ resident, a new student for the Intridden Exam or the Board Examps, they can reach out to me, I tutor for those, or you know, like a college body that needs to be for the Amcass or Primate Subjects, also to your for those. And then please subscribe to the You Tube channel. It's called Divine Intervention USMD Podcasts and Videos.

And I also have these podcasts on like Apple Podcasts, Spotify, Google Play, right? And also you can subscribe to the podcast website, right? Divine Intervention Podcasts.com. And if you're interested in any of these things, you can email me through the website, or you can send me an email at Divine Intervention Podcasts with an SIVN.gmail.com. And to be honest, fortunately, I don't really have a life lesson. Well, actually, I do have a life lesson. And I'll just say it's the importance of being a finisher, the thing is, it's not really good to be a person of a band-on project, right? If you start something, kind of be committed to finishing it, right? Because again, it's not the person that starts that gets credit, it's the person that actually finishes the gets credit, right? So, I'll just encourage you, if you start some, before you start something, count the costs, right? Count the cost, count the cost, but commit yourself to finishing. Don't be that kind of person that starts something and then jumps off-shipper the moment a little difficulty arises, right? That's not very nice and light for it. You know, you want to be a person that has team power, right? Because again, that top situation that may arise, you know, it just be a temporary inconvenience or temporary circumstance. Most bad things usually don't last forever, right? So, you know, just have some steam power. But I think that's what I'm going to say.

I'll have like a bigger life lesson, hopefully the next podcast I have. So, thank you for listening, really appreciate it, and I will see you in the next podcast. Thank you for listening. God bless you. Good night.

CCR5 and CXCR4.

Homozygous A32 mutation.

AIDS requires an HIV-positive individual plus evidence of an AIDS-defining illness (e.g., MAC, PCP, Kaposi's sarcoma).

Annually (compared to every three years in immunocompetent individuals).

GP120 (attachment) and GP41 (fusion/entry).

Nucleoside Reverse Transcriptase Inhibitors (NRT Is).

Monitor for G6 PD deficiency before starting the medication.

Reverse transcriptase.

Progressive Multifocal Leukoencephalopathy; < 100 cells/mm³.

Maraviroc.

NRT Is (competitive inhibitors of reverse transcriptase) and Protease Inhibitors (P Is).

Fluconazole plus Amphoterysin B.

Metabolic syndrome and lipodystrophy.

All necessary prophylactic antibiotics/antifungals.

Reverse transcriptase.

Progressive Multifocal Leukoencephalopathy; < 100 cells/mm³.

Maraviroc.

NRT Is (competitive inhibitors of reverse transcriptase) and Protease Inhibitors (P Is).

Fluconazole plus Amphoterysin B.

Metabolic syndrome and lipodystrophy.

All necessary prophylactic antibiotics/antifungals.