Download A 35-year-old man is diagnosed with HIV infection after he

1. A 35-year-old man is diagnosed with HIV infection after he sought testing because of
sexual exposure to another man approximately 5 years ago who he subsequently learned
was HIV-infected. The patient is asymptomatic. Medical history is unremarkable, and he
takes no medications.
On physical examination, he appears healthy. Vital signs and general examination are
normal. The liver and spleen are not enlarged.
Laboratory Studies
CD4 cell count
184/µL (0.184 × 109/L)
Plasma HIV RNA viral load
13,043 copies/mL
Serum aspartate aminotransferase
63 U/L
Serum alanine aminotransferase
85 U/L
Serum alkaline phosphatase
88 U/L
Serum total bilirubin
0.9 mg/dL (15.39 µmol/L)
Antibodies to hepatitis C virus (anti-HCV)
Negative
Hepatitis B surface antigen (HBsAg)
Positive
Antibodies to hepatitis B core antigen (anti-HBc)
Positive
Antibodies to hepatitis B surface antigen (anti-HBs)
Negative
Which of the follow ing is the most appropriate antiretroviral therapy at this time?
A
Delay treatment until the patient becomes symptomatic
B
Delay treatment until the patient's HIV RNA viral load exceeds 100,000 copies/mL
C
Begin treatment with zidovudine, didanosine, and nelfinavir
D
Begin treatment with emtricitabine, efavirenz, and tenofovir
2. A 38-year-old man with HIV infection and hepatitis C is evaluated after moving to a new
city. HIV infection and hepatitis C were diagnosed 1 year ago, at which time his CD4 cell
count was 523/μL (0.523 × 10 9 /L), and his plasma HIV RNA viral load was 8522 copies/mL.
The patient has remained asymptomatic, and his previous physician did not recommend
antiretroviral therapy.
On physical examination at today's visit, he appears well. His liver is not enlarged, his
spleen is not palpable, and there are no signs of liver disease. The remainder of the
examination is normal.
Laboratory Studies
CD4 cell count
449/μL (0.449 × 109/L)
Plasma HIV RNA viral load
12,220 copies/mL
Liver chemistry studies
Normal
Serum albumin
Normal
Prothrombin time
Normal
Which of the follow ing is the most appropriate management of this patient's hepatitis
C at this time?
A
Qualitative hepatitis C virus RNA viral load testing
B
Liver biopsy
C
Pegylated interferon
D
Pegylated interferon and ribavirin
3. A 35-year-old man is evaluated because of a lesion on his right arm that he first noticed 2 weeks
ago. The patient has a 4 -year history of HIV infection, most likely acquired after having sex with
another man. He has been asymptomatic until now and has never received antiretroviral therapy.
His lowest CD4 cell count was 382/μL (0.382 × 10 9 /L), and his plasma HIV RNA viral load has
ranged from 15,000 to 20,000 copies/mL.
On physical examination, the patient appears well. Vital signs are normal. There is a small, raised,
nontender, violaceous lesion on his right arm. Examination of the skin and mucous membranes is
otherwise normal. There is no lymphadenopathy or peripheral edema. Abdominal examination,
including rectal examination, is nor mal. A stool specimen is negative for occult blood.
Laboratory Studies
Complete blood count
Normal
CD4 cell count
402/μL (0.402 × 109/L)
Plasma HIV RNA viral load
14,355 copies/mL
Liver chemistry studies
Normal
Renal function studies
Normal
A chest radiograph is normal. Pathologic examination of an excisional biopsy specimen of the
lesion on his arm shows spindle cells and other features consistent with Kaposi's sarcoma.
Which of the follow ing is the most appropriate treatment at this time?
A
Begin highly active antiretroviral therapy (HAART) and systemic chemotherapy for Kaposi's
sarcoma
B
Begin HAART; defer systemic chemotherapy until the HIV infection is controlled
C
Begin HAART; defer systemic chemotherapy unless visceral or extensive skin involvement
develops
D
Begin systemic chemotherapy; defer HAART until the chemotherapy is completed
4. A 39-year-old man with a 12-year history of HIV infection comes for an initial evaluation
after moving to a new state. One month before moving, he was hospitalized for treatment of
cryptococcal meningitis and is now receiving fluconazole as long -term maintenance
therapy. The patient has taken numerous antiretroviral agents and has required several
changes in medications in an attempt to suppress the HIV infection completely. His current
regimen, which he has been on for 1 year, includes indinavir (800 mg), ritonavir (100 mg),
stavudine (40 mg), and didanosine (200 mg), all taken twice daily.
The patient generally feels well except for fatigue. Physical examination is normal. Results
of a CD4 cell count, plasma HIV RNA viral load, and HIV genotype resistance assay are
pending.
In addition to the genotype resistance assay result, w hich of the follow ing is most
important for determining a revised antiretroviral regimen?
A
The current viral load
B
The CD4 cell count nadir
C
The presence of symptoms
D
The duration of HIV infection
E
The history of use of antiretroviral agents
5. A 25-year-old woman, who is 8 weeks pregnant, is referred by her obstetrician for management
of newly diagnosed HIV infection found during routine prenatal s creening. This is the patient's first
pregnancy. She had never been tested for HIV before and does not know how long she has been
infected.
On physical examination, she appears well. Vital signs and general examination are normal except
for the presence of thrush.
Laboratory Studies
Hemoglobin
10.2 g/dL (102 g/L)
Hematocrit
31%
Leukocyte count
3900/μL (3.9 × 109/L)
Liver chemistry studies
Normal
Renal function studies
Normal
CD4 cell count
72/μL (0.072 × 109/L)
Plasma HIV RNA viral load
39,390 copies/mL
Trimethoprim–sulfamethoxazole is begun for treatment of thrush.
Which of the follow ing is most appropriate for treating this patient's HIV infection?
A
Begin zidovudine, lamivudine, and nelfinavir now
B
Begin lamivudine, tenofovir, and efavirenz now
C
Defer highly active antiretroviral therapy until the end of her first trimester
D
Defer highly active antiretroviral treatment until the end of her second trimester