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    usmlemate is offline Junior Member
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    Appropriate Vaccinations

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    A 35-year-old HIV-infected woman presents to clinic with recently diagnosed HIV infection. Her risk factors for acquiring HIV disease consist of injection-drug use and heterosexual sex with a partner known to have HIV. Initial laboratory tests show a CD4 count of 426 cells/mm3, HIV RNA of 32,000 copies/mm3, negative total hepatitis A virus antibody, negative hepatitis B virus surface antigen, positive hepatitis B surface and core antibodies, and positive hepatitis C virus antibody. Subsequent laboratory testing showed a hepatitis C virus RNA level of 2,300,000 copies/ml. The patient reports that she received all required childhood vaccinations and received a tetanus booster 2 years ago, but she does not recall ever having chicken pox or shingles.

    Which one of the following is TRUE regarding vaccinations for this patient?

    A. Pneumococcal vaccine should be given if the patientís CD4 count declines to less than 200 cells/mm3.

    B. The patient should receive the hepatitis A virus vaccine series.

    C. Influenza vaccine should not be given to this patient because influenza vaccine is likely to cause a marked increase in HIV RNA levels, a significant decline in CD4 cell count, and an acceleration of HIV disease.

    D. Varicella serology should be checked and, if negative, varicella vaccine should be given.

  2. #2
    usmlemate is offline Junior Member
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    Re: Appropriate Vaccinations

    Quote Originally Posted by usmlemate
    A 35-year-old HIV-infected woman presents to clinic with recently diagnosed HIV infection. Her risk factors for acquiring HIV disease consist of injection-drug use and heterosexual sex with a partner known to have HIV. Initial laboratory tests show a CD4 count of 426 cells/mm3, HIV RNA of 32,000 copies/mm3, negative total hepatitis A virus antibody, negative hepatitis B virus surface antigen, positive hepatitis B surface and core antibodies, and positive hepatitis C virus antibody. Subsequent laboratory testing showed a hepatitis C virus RNA level of 2,300,000 copies/ml. The patient reports that she received all required childhood vaccinations and received a tetanus booster 2 years ago, but she does not recall ever having chicken pox or shingles.

    Which one of the following is TRUE regarding vaccinations for this patient?

    A. Pneumococcal vaccine should be given if the patientís CD4 count declines to less than 200 cells/mm3.

    B. The patient should receive the hepatitis A virus vaccine series.

    C. Influenza vaccine should not be given to this patient because influenza vaccine is likely to cause a marked increase in HIV RNA levels, a significant decline in CD4 cell count, and an acceleration of HIV disease.

    D. Varicella serology should be checked and, if negative, varicella vaccine should be given.
    The correct answer is B. Hepatitis A vaccine is recommended for all persons with chronic liver disease (especially chronic hepatitis C), patients with multiple sexual partners, men who have sex with men, and for those planning to travel to a region endemic for hepatitis A virus. This vaccine does not contain live virus and does not pose any special risk to HIV-infected persons.

    Answer A is incorrect. Pneumococcal vaccine is recommended for all HIV-infected persons. Because of diminished vaccine immune responses in patients with severe immune deficiency, it is preferable to administer pneumococcal vaccine before the CD4 count decreases to less than 200 cells/mm3. For patients with a CD4 count less than 200 cells/mm3, it is preferable to delay giving pneumococcal vaccine until sustained immune reconstitution occurs as a result of antiretroviral therapy. One-time revaccination should be considered for patients who received pneumococcal vaccine more than 5 years earlier or who were vaccinated at a time when their CD4 count was less than 200 cells/mm3.

    Answer C is incorrect. Annual influenza vaccine is recommended for all persons infected with HIV. The killed influenza virus vaccine does not pose a risk of active influenza infection. The live attenuated intranasal influenza vaccine (Flumist) is not recommended for HIV-infected persons. Although early studies suggested influenza vaccine might adversely affect HIV RNA levels, prospective studies have not found influenza vaccination to result in significant adverse effects on HIV RNA levels, CD4 counts, and progression of HIV disease.

    Answer D is incorrect. Varicella vaccine contains live, attenuated virus and is contraindicated for all HIV-infected adults. Among adults who do not recall prior varicella illness, more than 90% will have serologic evidence of prior infection. Those who are seronegative can be treated with varicella zoster immune globulin if they are exposed to a patient with active varicella.

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