Immunoglobulins

Data regarding the use of immunoglobulins as adjunctive therapy for the treatment of

select infections in the neutropenic cancer patient are primarily limited to case

reports. Patients with pneumonia secondary to CMV may benefit from adjunctive

immunoglobulin therapy (in combination with ganciclovir). In addition, IV

immunoglobulin G should be considered in those patients with

hypogammaglobulinemia.

G-CSF administration, although likely to reduce the duration of her chemotherapyinduced neutropenia, is not indicated in S.B., who is otherwise stable.

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p. 1570

Acute retroviralsyndrome is characterized by nonspecific symptoms,

such as fever, lymphadenopathy, rash, fatigue, and night sweats that

coincide with an initial burst of viremia. These symptoms, as well as the

presence of an opportunistic infection, and high-risk sexual or drug-using

behaviors, warrant human immunodeficiency virus (HIV) testing. With

current antigen/antibody laboratory tests, HIV can be diagnosed as

early as 2 weeks after infection. In patients in whom very early

infection (<2 weeks) is suspected, nucleic acid tests for HIV RNA may

be considered for diagnostic purposes.

Case 76-1 (Question 1)

HIV RNA viral load is measured to quantify the level of viral replication

in the body and CD4 cell counts are followed to assess immune system

function.

Case 76-1 (Question 2)

Antiretroviral therapy should be offered to all patients who are willing

and able to commit to lifelong treatment after a discussion of the

benefits and risks of highly active antiretroviral therapy (HAART) and

the importance of adherence. Clinicalsituations which favor more

urgent initiation of HAART include pregnancy; AIDS-defining condition

such as an opportunistic infection; CD4 count of <200 cells/μL; HIVassociated nephropathy (HIVAN); hepatitis B and/or C infection;

rapidly declining CD4 count (>100 cells/μL decrease per year); higher

baseline viral load (>100,000 copies/mL); and acute/early HIV infection.

US Department of Health and Human Services (DHHS) guidelines

provide recommendations for optimal antiretroviral therapy.

Case 76-1 (Question 3)

Goals of antiretroviral therapy include suppression of viral load,

preservation and strengthening of the immune system, limitation of drug

adverse events, promotion of adherence, and prevention of HIV-related

morbidity and mortality.

Case 76-1 (Question 4)

General rules of therapy involve selection of HAART-based regimen,

optimization of the selected agents, and inclusion of quality of life in

decisions.

Case 76-1 (Questions 5, 6)

After initiating a HAART regimen, short-term goals include resolution of

symptoms, at least a threefold (0.5 log) decrease in HIV RNA at 1

month, a tenfold decrease (1.0 log) in HIV RNA at 2 months, and an

increase in CD4 count at 3 to 4 months. Long-term assessments include

Case 76-1 (Questions 7, 8)

the monitoring of HIV RNA and CD4 count every 3 to 6 months to

identify treatment failures, assessment of medication adherence, and

determination of tolerability and quality of life.

General rules for changing failing regimens include switching to at least

two new active drugs (although all new drugs are preferable), as quickly

as possible after treatment failure to avoid accumulation of resistance

mutations. To avoid the development of further resistance, a single drug

should never be added to a failing regimen. If one drug must be

discontinued, the whole regimen should be stopped simultaneously.

Finally, previously failed regimens should never be restarted because of

the potential of archived resistance mutations.

Case 76-1 (Questions 9, 10)

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