I .

HIV infection :
HIV: high risk patient, oral manifestation, investigation, complication ?

*mode of transmission:
1. sexual : homosexual and heterosexual.
2. parental : transmission in recipients of blood or blood product and
injection of drug user
3. vertical : from mother to baby

* risk factor (patient):

1. sexual transmitted infection, especially genital ulcer
2. injection drug use transmission : sharing needle, frequency of use, prostitutes,
intravenous use.
3. occupational transmission ( nurse, doctor, lab worker ) deep injury,
visible blood on device
4. vertical transmission : ( peripartum and breast feeding )

* natural history :
1. primary infection/ seroconversion :
-Is symptomatic and occurs 2-4 weeks after exposure (incubation period )
-clinical feature :
Fever – erythematous – fatigue – mucosal ulceration – headache –
Opportunistic infections such as oropharyngeal candidiasis.
-recovery occurs in 1-2 weeks but may take up to 10 weeks
2. asymptomatic infection / clinical latency :
-no evidence of disease
-persistent of generalized lymphoadenopathy
-the virus continues to replicate
-the median time is 10 yrs from infection to development the AIDS.
3. mildly symptomatic disease:
- chronic weight loss, fever, diarrhea, oral or vaginal candidiasis,
oral hairy leukoplakia, recurrent herpes zoster, sever pelvic
inflammatory disease, cervical dysplasia & ITP
4. AIDS :
- development of specified opportunistic infections and tumors.
- progresses the viral load rises
- CD4 count falls
-kaposi's sarcoma, Cryptococcus, histoplasmosis

* clinical syndrome :
-mucocutaneous manifestation
- gastrointestinal effect - eye disease
- hematological complication - renal complication
- respiratory complication - cardiac complication
- neurological disease

*oral manifestation:
- oropharyngeal candidiasis - mucosal ulceration in the mouth
- oral candidiasis - oral hairy leukoplakia
- aphthous ulcer - SSC

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 - kaposi' sarcoma - fungal infection
- lymphoma

*complication:
- kaposi's sarcoma - Cryptococcus - molluscum contagiousm
- histoplasmosis - non-hodgkin's lymphoma

*investigation :
-HIV antibody : confirmation of HIV by ELISA antibody testing
- PCR for HIV RNA
- viral load ( HIV RNA ): by PCR or bDNA or NASBA method
- absolute CD4 count

* management :
Antiretroviral drugs :
- Nucleoside reverse transcriptase inhibitors
- Non-Nucleoside reverse transcriptase inhibitors
- Protease inhibitors

II . Asthma & COPD:

1. COPD : causes, sign, symptoms, investigation, complication ?

*Definition:
airflow limitation that is not fully reversible due to chronic bronchitis or
emphysema. The airflow limitation is progressive and associated with
abnormal inflammatory response of the lungs to noxious particles or gases.

*Causes:
1- cigarette smoking is the primary cause.
2-Air pollution, airway infection, allergy and familial disorder.
3-Alpha 1- antitrypsin deficiency.

*Risk factors:
Host factors:
- genes (alpha 1- antitrypsin deficiency).
- hyper responsiveness.
- lung growth.
Exposure:
- tobacco smoke.
- Occupational dust and chemicals.
- Infections.
- Socioeconomic status.

*Signs:
Inspection:
- dyspnea
- accessory muscles of respiration are used (sternomastoid, scalene).
- pursing of lips.
- reduction in the length of trachea above the sterna notch.

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 - tracheal tug.
- jugular venous distention during expiration.
- chest becomes barrel-shaped.
- central cyanosis.
Palpation:
-percussion note is hyper-resonant.
- loss of normal area of cardiac & liver dullness.
Auscultation:
-breath sounds are decreased.
- prolonged expiration.
- coarse crepitations.
- rhonchi at expiration.

*Symptoms:
Cough: tightness in the chest.
Expectoration: sputum.
Dyspnea: on heavy exertion.

*Investigations:
-Chest x-ray - ABGs.
- pulmonary function test. - sputum culture & sensitivity.
- ECG: tall P wave. - alpha 1- antitrypsin deficiency.
- echocardiography: to assess pulmonary artery pressure.

*Complications:
-type 1 & type 2 respiratory failure.
- secondary polycythemia.
- spontaneous pneumothorax.
- acute bronchitis, pneumonia.
- pulmonary hypertension and right ventricular failure (corpulmonale).
Hypoxia à pulmonary arteriolar vasoconstrictionà pulmonary hypertension à RT
heart failure (cor pulmonale).

2. bronchial asthma : definition, type, precipitating factor?

sign and symptom of acute exacerbation?

* Definition :
the narrowing of bronchial airway is due to muscle spasm, mucosal swelling
and viscid bronchial secretion (paroxysmal narrowing) chronic inflammation
leads to increase airway hyperresponsiveness with recurrent episodes of
wheezing, coughing and shortness of breath.

* Types :
-early onset asthma (episodic, atopic or extrinsic asthma)
-late onset asthma (chronic or non-atopic or intrinsic asthma)

* Etiology :
- atopy and allergy
- airway hyperactivity

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 * Pathogenesis :
-inflammation and asthma
-immediate response
-late phase response (or reaction)

*Precipitating factor :
- abrupt changes in weather -cold air
- dust, tobacco smoke, atmospheric pollution -exercise
- respirator viral infection -emotional stress
- drugs and other NSAID, beta-blockers

*Investigation :
- chest x-ray - peak expiratory flow rate
- arterial blood gases

*Complication :
- dehydration - airway infections - exhaustion
- pneumothorax - respiratory failure - Cor pulmonale

*Management :
- prevention :
- Avoid :
- causative allergens,
- beta-blockers
- ACE-inhibitor drugs
- early ttt - stop smoking,
- pneumococcal vaccination, - hyposensitization (vaccination).
- treatment :
- long term control medication
Inhaled steroid, long acting beta2 agonist, antileukotrienes,
methylxanthines, systemic steroid
- quick-relief medication
Short acting beta2 agonist, anticholinergics, systemic steroids

Acute sever asthma :

*sign:
- sever shortness of breath - cannot speak
- central cynosis - cannot lie down
- unable to speak - relative bradycardia
- unrecordable PEF - O2 saturation <1%
- exhaustion, confusion, reduced conscious level

*Symptoms:
- feeling of tightness in the chest - episode of dyspnea
- unproductive cough which aggravates the dyspenea - wheeze

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 III . Infective endocarditis :
What are the clinical feature of infective endocarditis ?
Sign, symptom, complication of infective endocarditis ?

* Clinical features (signs & symptoms):

- General sestems: malaise , clubbing, anorexia, weight loss, night sweats,
fatigue.
- Cardiac features: murmurs, cardiac failure.
- Arthralgia, back pain.
- Pyrexia
- Features of immune vasculitis (Skin lesions): osler's nodes, splinter
hemorrhage, janeway lesions, petechiae.
- Eyes: roth spots, conjunctival, splinter hemorrhages.
- Splenomegaly.
- Neurological: cerebral emboli, mycotic aneurysm.
- Renal: haematuria.
- Features of embolism: stroke, sever limb pain, pulmonary or myocardial
infarction.

* Complications:
1- Cardiac complications:
- CHF.
- valvular damage.
- valvular stenosis.
- abscess extending to myocardium (conduction disturbances) and
pericardium (purulent pericarditis).
- coronary embolism.
- prosthetic dehiscence.
2- extracardiac complications:
- Embolism (cerebral - renal - splenic).
- stroke
- blindness
- gangrenous extremities
- unusual pain syndromes
- paralysis
- Abscesses.
- Pulmonary abscess or infarction.
- Immune complex (arthritis – glomerulonephritis).

Done by:
Turki Alkhallagi
Shaymaa Mudhaffer
Sumayah Halabi
4th year
2009 – 2010

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