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Group 1

PLENO
SCENARIO 5
Member of Group 1
Adityo Muhammad Farid 1118011001
Bela Riski Dinanti 1118011019
Cici Yuliana Sari 1118011025
Desta Eko Indrawan 1118011029
Dina Rianti Fitri 1118011035
Gilang Yoghi Pratama 1118011048
I Gede Eka Widayana 1118011057
Karimah Ihda Husnayain 1118011064
Magista Vivi Anisa 1118011071
Resti Ramdhani 1118011108
SCENARIO 5
Mr. X 35 years old, is taken by his wife to the
emergency unit because of weak and almost
fainted. After being asked, Mr.X is having diarrhea
and vomitting from the day before. According to
his wife, its not the first time that her husband
suffering from this condition. Her wife who is
pregnant says that her husband was a drug user
too and after being fired from his job in Jakarta
and come back to his village. Her husband has
often getting sick. In last six months Mr.X has
been becoming thinner and easily getting cough
and cold. From the result of Physical
Examination, there is oral thrush inside his
mouth. Doctor suggests Mr.X to do some
laboratory examination.
STEP 1
There is no Terminology
STEP 2
1. What is the diagnosis of Mr.X and differential
diagnosis?
2. What is the etiology and risk factors?
3. What is the Physical Examination that needed
for Mr.X?
4. What is the Laboratory Examination that
needed for Mr.X?
5. How about the management for Mr.X & how
about the Prevention for that case?
1. Diagnose and diferential diagnose from the
scenario
Diagnose : HIV AIDS
DD :
- Tuberculosis
- Herpes simpleks
- Toxoplasmossis
- Cytomegalovirus
- Candidiasis
- Cryptococcis
- etc

STEP 3
2. Etiology and Risk Factors
Etiology :
HIV (Human Immunodeficiency Virus)


Risk Factors :
Through Bodily Fluids
Through Sex
Mother to baby


3. PHYSICAL EXAMINATION
Vital Signs
Region
4. LABORATORY EXAMINATION

HIV enzyme-linked immunosorbent
assay (ELISA)
Screening test for HIV
Sensitivity > 99.9%
Western blot Confirmatory test
Speicificity > 99.9% (when combined with
ELIZA)
HIV rapid antibody test Screening test for HIV
Simple to perform
Absolute CD4 lymphocyte count Predictor of HIV progression
Risk of opportunistic infections and AIDS when
<200

HIV viral load tests Best test for diagnosis of acute HIV infection
Correlates with disease progression and
response to HAART
5. Prevention and Management
Prevention :
VCT (Voluntary Counseling and Testing)

VCT provides the opportunity for people to know their HIV
status with quality counseling support to help them cope with
a positive or a negative test result.
The majority of adult populations are HIV negative, even in
high HIV prevalence settings. Knowing one is HIV negative
can serve as a strong motivating factor to remain negative,
particularly for those who may otherwise assume it is too late
to adopt safer sexual practices.
For people who test positive, while VCT services can link
them to options for treatment if and where they exist, and to
care and support, just as important, it allows for adoption of
preventive measures.

Management:

Adherence.
General Health.
Additional precautions.
Long-term condition.
Psychological.
STEP 4
1. Diagnose : HIV AIDS
AIDS (Acquired immune deficiency syndrome or
acquired immunodeficiency syndrome) is a disease
caused by a virus called HIV (Human
Immunodeficiency Virus). The illness alters the
immune system, making people much more
vulnerable to infections and diseases. This
susceptibility worsens as the disease progresses.

HIV is found in the body fluids of an infected person
(semen and vaginal fluids, blood and breast milk).
The virus is passed from one person to another
through blood-to-blood and sexual contact. In
addition, infected pregnant women can pass HIV to
their babies during pregnancy, delivering the baby
during childbirth, and through breast feeding.
Differential Diagnosis:

Most common
Epstein-Barr virus
Influenza
Streptococcal pharyngitis
Viral/noninfectious gastroenteritis
Viral upper respiratory tract infection
Less common
Acute viral hepatitis
Drug reaction
Primary herpes simplex infection
Secondary syphilis
Least common
Acute cytomegalovirus infection
Acute toxoplasmosis
Measles
Meningitis/encephalitis
Primary immunodeficiencies
Rubella
(Bikle D. D. 2009)
2. Etiology and Risk Factors
HIV (Human
Immunodeficiency Virus)


The outer shell of the virus is
known as the Viral enevlope.
Embedded in the viral
envelope is a complex protein
known as env which consists
of an outer protruding cap
glycoprotein (gp) 120, and a
stem gp14. Within the viral
envelope is an HIV protein
called p17(matrix), and within
this is the viral core or capsid,
which is made of another viral
protein p24(core antigen).
(Kumar, Abbas, Fausto, 2005)
Characteristics of the virus :

Icosahedral (20 sided),
enveloped virus of the
lentivirus subfamily of
retroviruses.

Retroviruses transcribe RNA to
DNA.
Two viral strands of RNA found
in core surrounded by protein
outer coat.
Outer envelope contains a lipid
matrix within which specific
viral glycoproteins are
imbedded.

These knob-like structures
responsible for binding to
target cell.
(Kumar, Abbas, Fausto, 2005)
HIV virion


(Kumar, Abbas, Fausto, 2005)
Life Cycle of HIV
Stages:
1.Attachment: Virus binds to surface
molecule (CD4) of T helper cells and
macrophages.
Coreceptors: Required for HIV infection.
CXCR4 and CCR5 mutants are resistant to
infection.
2.Fusion: Viral envelope fuses with cell
membrane, releasing contents into the cell.
(Abrams DI et al. 2007)
3. Reverse Transcription: Viral RNA is
converted into DNA by unique enzyme
reverse transcriptase.
Reverse transcriptase
RNA ---------------------> DNA
Reverse transcriptase is the target of
several HIV drugs: AZT, ddI, and ddC.
(Abrams DI et al. 2007)
Life Cycle of HIV
4. Integration: Viral DNA is inserted into host cell
chromosome by unique enzyme integrase. Integrated
viral DNA may remain latent for years and is called a
provirus.
5. Replication: Viral DNA is transcribed and RNA is
translated, making viral proteins.
Viral genome is replicated.
6. Assembly: New viruses are made.
7. Release: New viruses bud through the cell membrane.
(Abrams DI et al. 2007)
Life cycle of HIV (Kumar, Abbas dan Fausto, 2005)

Pathogenesis
of HIV




(Kumar, Abbas,
Fausto, 2005)
Risk Factor
Through Bodily Fluids
Blood products
Semen
Vaginal fluids

(Baggaley, R. F., White, R. G., Boily, M. C. 2010)
Through Sex
Unprotected Intercourse
Oral
Anal
(Baggaley, R. F., White, R. G., Boily, M. C. 2010)
Mother-to-Baby

Before Birth
During Birth
(Baggaley, R. F., White, R. G., Boily, M. C. 2010)
HIV Transmission in United States and
the Rest of the World
(Baggaley, R. F., White, R. G., Boily, M. C. 2010)
3. PHYSICAL EXAMINATION

a. VITAL SIGNS
Height
Weight
Tempterature
Blood pressure
Heart rate
Respiratory rate
Oxygen saturation
Waist, hip circumferences
Body mass index (BMI)
(McGowan I. 2008)
b. REGION

General
Eyes
Ears/Nose
Oral Cavity
Endocrine
Lymph Nodes
Lungs
Heart
Breasts

Abdomen
Genitals / Rectum
Female Patients
Male Patients
Extremities /
Musculoskeletal
Habitus
Skin
Neurologic
Psychiatric

(McGowan I. 2008)
4. LABORATORY EXAMINATION

HIV enzyme-linked immunosorbent
assay (ELISA)
Screening test for HIV
Sensitivity > 99.9%
Western blot Confirmatory test
Speicificity > 99.9% (when combined with
ELIZA)
HIV rapid antibody test Screening test for HIV
Simple to perform
Absolute CD4 lymphocyte count Predictor of HIV progression
Risk of opportunistic infections and AIDS when
<200

HIV viral load tests Best test for diagnosis of acute HIV infection
Correlates with disease progression and
response to HAART
(McGowan I. 2008)
Other examination
Urinalisis
CSF examination
Feses Analysis
(McGowan I. 2008)
5. Prevention

VCT (Voluntary Counseling and Testing)

Typically, a classic VCT service package ensures that:

Knowledge of status is voluntary;
Pre-test counseling is offered either through one or more sessions with
a trained counselor, after which the client may choose to test on the
same or different day;
Informed consent is obtained from the client by a service provider;
HIV test is performed using approved HIV test kits and testing protocols
(refer to appendix 1 - fact sheet of the various types of test available);
Post test counseling (one or more sessions) that includes informing
clients of their HIV test results, takes place on the same or different day.

Testing for HIV without pre- and post-test counseling should not be
recommended


(Aberg, J. A., Kaplan, J. E., Libman, H,. 2009)
Therapy
Antiretroviral Drugs (HAART)

Nucleoside Reverse Transcriptase inhibitors
AZT (Zidovudine)
Non-Nucleoside Transcriptase inhibitors
Viramune (Nevirapine)
Protease inhibitors
Norvir (Ritonavir)
Management
Adherence. HIV treatment is effective if the patient is committed and constant
in taking the medication on time. Missing even a few doses will jeopardize the
treatment. A daily methodical routine has to be programmed to fit the treatment
plan around the patient's lifestyle and schedule. "Adherence" is sometimes
known as "compliance".

General Health. It is crucial for patients to take medication correctly and take
steps to avoid illness. Patients should seek to improve their general health and
reduce the risk of falling ill by practicing regular exercise, healthy eating, and
not smoking.

Additional precautions. HIV-infected people should be extra cautious to
prevent exposure to infection. They should be careful around animals, avoid
coming into contact with cat litter, animal feces. Meticulous and regular
washing of hands is recommended.

Long-term condition. HIV is a lasting condition, and therefore patients have
to be in regular contact with their healthcare team. Treatment plan is reviewed
regularly.

Psychological. Common misconceptions about AIDS/ HIV are diminishing.
However, the stigma of the disease persists in many parts of the world. People
infected with the virus may feel excluded, rejected, discriminated and isolated.

Being diagnosed with HIV can be very distressing, and feelings of anxiety or
depression are common. If you feel anxious or have symptoms of depression,
seek medical help immediately.
(McGowan I. 2008)
When to start treatment?
You have severe symptoms
Your CD4 count is under 500
Youre pragnant
You have HIV related kidney disease
Youre being treated for hepatitis B
STEP 5
1. If the pregnant women with HIV (+) have a
baby, may the baby will be infected too?
2. How about the prevention to prevent the
transmission between mother with HIV (+) to
child?
3. Medical Ethics for HIV/AIDS
STEP 6

Independent Learning
1. If the pregnant women with HIV (+) have a baby,
may the baby will be infected too?

These are some factors that have a role about HIV
transmission from mother to child :

MATERNAL FACTORS
- Advanced HIV disease : High HIV RNA, low CD 4
- Co- infection
- Drug abuse
- Obstetric complications : prolonged rupture of amniotic
membran
- Breast- feeding
STEP 7
(Zuccotti GV et al. 2006)
FETAL FACTORS
- Chorioamnionitis
- Disruption of placenta : maternal fetal blood exchange
- Birth trauma
- Twin : 1
st
twin has a higher risk
- Prematurity

OBSTETRIC FACTORS
- Cervicovaginal infection
- Prolonged membran rupture
- Preterm labor < 37 week
- STD
- Bleeding at labor
- Invasive procedure

(Zuccotti GV et al. 2006)
2. PMTCT
(McGowan I. 2008)
3. Medical ethics for HIV/AIDS
Problem identification
Problem diagnose
Goal and Planning alternative
Action
Monitoring and evaluation
(megan)
(Zuccotti GV et al. 2006)
The doctor/ patient relationship is founded on mutual
trust and respect
The doctor will extend to HIV infected or AIDS
patient the same high standart of medical care and
support which they would offer to anny other patient.
Doctor who think they may have been infected with
HIV should seek appropiate diagnostic testing and
counseling
(general medical council of United Kingdom)
(Zuccotti GV et al. 2006)
REFERENCES
Aberg, J. A., Kaplan, J. E., Libman, H., et al. "Primary Care Guidelines for the
Management of Persons Infected with Human Immunodeficiency Virus: 2009
Update by the HIV Medicine Association of the Infectious Diseases Society of
America." Clin Infect Dis49.5 (2009): 651-81.

Abrams DI et al. Dehydroepiandrosterone (DHEA) effects on HIV replication and host
immunity: a randomized placebo-controlled study. AIDS Res Hum Retroviruses.
2007 Jan;23(1):77-85.

Baggaley, R. F., White, R. G., Boily, M. C. "HIV Transmission Risk through Anal
Intercourse: Systematic Review, Meta-Analysis and Implications for HIV
Prevention." Int J Epidemiol 39.4 (2010):1048-63.
http://ije.oxfordjournals.org/content/39/4/1048.full

Herzenberg, L. A., De Rosa, S. C., Dubs, J. G., et al. "Glutathione Deficiency Is
Associated with Impaired Survival in HIV Disease." Proc Natl Acad Sci U S A 94.5
(1997): 1967-72. http://www.pnas.org/content/94/5/1967.full.pdf

McGowan I. Rectal microbicides: a new focus for HIV prevention. Sex Transm Infect.
84.6 (2008): 413-7.

Zuccotti GV et al. Oral lactoferrin in HIV-1 vertically infected children: an observational
follow-up of plasma viral load and immune parameters. J Int Med Res. 2006 Jan-
Feb;34(1):88-94