MCQ Quiz: HIV Opportunistic Infections

For individuals living with HIV, particularly those with advanced immunosuppression, opportunistic infections (OIs) pose a significant threat to health and survival. The management of these infections is a critical component of comprehensive HIV care. For PharmD students, mastering the guidelines for the prophylaxis and treatment of OIs is essential. This involves understanding CD4 count thresholds, selecting appropriate antimicrobial regimens, managing drug interactions with antiretroviral therapy (ART), and counseling patients on adherence. This quiz will test your knowledge on the most common and serious OIs, including Pneumocystis jirovecii pneumonia (PJP), Toxoplasma gondii encephalitis, and Mycobacterium avium complex (MAC) disease.

1. Primary prophylaxis for Pneumocystis jirovecii pneumonia (PJP) should be initiated in an adult with HIV when their CD4+ T-cell count drops below what threshold?

• a) 500 cells/mm³
• b) 200 cells/mm³
• c) 100 cells/mm³
• d) 50 cells/mm³

Answer: b) 200 cells/mm³

2. What is the preferred first-line agent for both treatment and primary prophylaxis of PJP?

• a) Dapsone
• b) Atovaquone
• c) Trimethoprim-sulfamethoxazole (TMP-SMX)
• d) Inhaled Pentamidine

Answer: c) Trimethoprim-sulfamethoxazole (TMP-SMX)

3. When treating moderate to severe PJP, what adjunctive therapy is recommended to be given with antibiotics to reduce the inflammatory response and improve survival?

• a) N-acetylcysteine
• b) Leucovorin
• c) Prednisone or another corticosteroid
• d) Furosemide

Answer: c) Prednisone or another corticosteroid

4. A patient with a sulfa allergy requires PJP prophylaxis. Which of the following is a recommended alternative regimen?

• a) Amoxicillin
• b) Dapsone
• c) Ciprofloxacin
• d) Rifampin

Answer: b) Dapsone

5. Primary prophylaxis for Toxoplasma gondii encephalitis is recommended for seropositive patients when their CD4+ count is below:

• a) 200 cells/mm³
• b) 150 cells/mm³
• c) 100 cells/mm³
• d) 50 cells/mm³

Answer: c) 100 cells/mm³

6. The preferred treatment regimen for acute toxoplasmosis encephalitis is the combination of pyrimethamine, sulfadiazine, and which other agent?

• a) Folic acid
• b) Pyridoxine
• c) Leucovorin
• d) Thiamine

Answer: c) Leucovorin

7. What is the purpose of administering leucovorin with pyrimethamine?

• a) To enhance the antimicrobial effect of pyrimethamine.
• b) To prevent pyrimethamine-induced hematologic toxicity (bone marrow suppression).
• c) To treat the underlying toxoplasmosis infection.
• d) To reduce the risk of a sulfa allergy.

Answer: b) To prevent pyrimethamine-induced hematologic toxicity (bone marrow suppression).

8. Prophylaxis against Mycobacterium avium complex (MAC) disease should be initiated in patients with HIV when their CD4+ count falls below:

• a) 200 cells/mm³
• b) 100 cells/mm³
• c) 50 cells/mm³
• d) Prophylaxis is not recommended regardless of CD4 count.

Answer: c) 50 cells/mm³

9. Which of the following is the preferred agent for primary prophylaxis of MAC disease?

• a) Isoniazid
• b) Rifampin
• c) Azithromycin or Clarithromycin
• d) Ethambutol

Answer: c) Azithromycin or Clarithromycin

10. The standard treatment for disseminated MAC disease involves a combination of which two drug classes?

• a) A macrolide (clarithromycin or azithromycin) plus ethambutol.
• b) A fluoroquinolone plus an aminoglycoside.
• c) Two different protease inhibitors.
• d) Isoniazid plus rifampin.

Answer: a) A macrolide (clarithromycin or azithromycin) plus ethambutol.

11. A patient with HIV presents with a creamy white plaque-like lesion in their mouth that can be easily scraped off. This is most characteristic of:

• a) Kaposi’s sarcoma
• b) Oral hairy leukoplakia
• c) Oropharyngeal candidiasis (Thrush)
• d) Aphthous ulcers

Answer: c) Oropharyngeal candidiasis (Thrush)

12. What is the first-line treatment for uncomplicated oropharyngeal candidiasis in a patient with HIV?

• a) Intravenous amphotericin B
• b) Oral fluconazole
• c) Oral itraconazole
• d) Topical nystatin

Answer: b) Oral fluconazole

13. Immune Reconstitution Inflammatory Syndrome (IRIS) occurs when:

• a) A patient’s CD4 count drops to a critically low level.
• b) A patient on ART develops a paradoxical worsening of a pre-existing infection due to their recovering immune system.
• c) A patient develops resistance to their antiretroviral regimen.
• d) A patient has a severe allergic reaction to an antibiotic.

Answer: b) A patient on ART develops a paradoxical worsening of a pre-existing infection due to their recovering immune system.

14. A patient with HIV and a CD4 count of 40 cells/mm³ presents with painless vision loss and “floaters.” A funduscopic exam reveals yellowish-white retinal lesions. This is characteristic of:

• a) Toxoplasmosis encephalitis
• b) Cryptococcal meningitis
• c) Cytomegalovirus (CMV) retinitis
• d) Progressive Multifocal Leukoencephalopathy (PML)

Answer: c) Cytomegalovirus (CMV) retinitis

15. What is the treatment of choice for sight-threatening CMV retinitis in a person with HIV?

• a) Oral acyclovir
• b) Intravenous ganciclovir or oral valganciclovir
• c) Oral fluconazole
• d) Trimethoprim-sulfamethoxazole

Answer: b) Intravenous ganciclovir or oral valganciclovir

16. A patient on PJP prophylaxis with dapsone should be screened for a deficiency in which enzyme to avoid a risk of hemolysis?

• a) HLA-B*5701
• b) Cytochrome P450 2C19
• c) Glucose-6-phosphate dehydrogenase (G6PD)
• d) UGT1A1

Answer: c) Glucose-6-phosphate dehydrogenase (G6PD)

17. Discontinuation of primary PJP prophylaxis is appropriate when a patient on ART has a CD4 count that is:

• a) > 200 cells/mm³ for at least 3 months.
• b) > 100 cells/mm³ for at least 3 months.
• c) > 50 cells/mm³ for at least 6 months.
• d) Prophylaxis should never be discontinued.

Answer: a) > 200 cells/mm³ for at least 3 months.

18. What is the most common CNS opportunistic infection in patients with AIDS?

• a) Cryptococcal meningitis
• b) CMV retinitis
• c) Toxoplasma gondii encephalitis
• d) PML

Answer: c) Toxoplasma gondii encephalitis

19. A patient with a sulfa allergy requires treatment for acute toxoplasmosis encephalitis. Which is a common alternative to sulfadiazine?

• a) Doxycycline
• b) Clindamycin (used in combination with pyrimethamine and leucovorin)
• c) Azithromycin
• d) Metronidazole

Answer: b) Clindamycin (used in combination with pyrimethamine and leucovorin)

20. A patient on ART has their CD4 count increase from 40 to 150 cells/mm³. When can MAC prophylaxis be discontinued?

• a) Immediately.
• b) When the CD4 count is > 100 cells/mm³ for at least 3 months.
• c) When the CD4 count is > 200 cells/mm³ for at least 3 months.
• d) When the viral load is undetectable.

Answer: b) When the CD4 count is > 100 cells/mm³ for at least 3 months.

21. A patient with AIDS develops fever, headache, and neck stiffness. A lumbar puncture reveals an extremely high opening pressure and a positive India ink stain. This is diagnostic for:

• a) Tuberculous meningitis
• b) Bacterial meningitis
• c) Cryptococcal meningitis
• d) Viral meningitis

Answer: c) Cryptococcal meningitis

22. The treatment of cryptococcal meningitis consists of an induction phase, a consolidation phase, and a long-term maintenance phase. What is the preferred agent for the maintenance phase?

• a) Amphotericin B
• b) Flucytosine
• c) Fluconazole
• d) Voriconazole

Answer: c) Fluconazole

23. The dosing of TMP-SMX for PJP treatment is based on which component?

• a) The sulfamethoxazole component.
• b) The trimethoprim component.
• c) The total weight of both components.
• d) A fixed dose regardless of weight.

Answer: b) The trimethoprim component.

24. Which of the following is NOT an AIDS-defining illness?

• a) Kaposi’s sarcoma
• b) Disseminated Mycobacterium avium complex (MAC)
• c) Community-acquired pneumonia caused by S. pneumoniae.
• d) Esophageal candidiasis.

Answer: c) Community-acquired pneumonia caused by S. pneumoniae.

25. Before starting primary prophylaxis for toxoplasmosis, what test should be performed?

• a) A Toxo TST skin test.
• b) A Toxoplasma IgG antibody test.
• c) A brain MRI.
• d) A blood culture.

Answer: b) A Toxoplasma IgG antibody test.

26. A patient on TMP-SMX for PJP treatment develops hyperkalemia. This is due to the trimethoprim component’s structural similarity to which drug?

• a) Furosemide
• b) Amiloride
• c) Spironolactone
• d) Hydrochlorothiazide

Answer: b) Amiloride

27. What is the most important strategy for preventing opportunistic infections in people with HIV?

• a) Lifelong antibiotic prophylaxis for all patients.
• b) Timely initiation and maintenance of effective antiretroviral therapy (ART).
• c) Regular vaccination against all known pathogens.
• d) Avoiding contact with all other people.

Answer: b) Timely initiation and maintenance of effective antiretroviral therapy (ART).

28. A patient with a severe sulfa allergy requires treatment for acute PJP. Which of the following is a potential parenteral alternative to TMP-SMX?

• a) IV Clindamycin + IV Primaquine
• b) IV Ceftriaxone
• c) IV Vancomycin
• d) IV Acyclovir

Answer: a) IV Clindamycin + IV Primaquine

29. The main reason for giving corticosteroids in moderate-to-severe PJP is to prevent:

• a) The development of a sulfa rash.
• b) Antibiotic-induced nephrotoxicity.
• c) Worsening hypoxemia that can occur after starting antimicrobial therapy.
• d) Fungal superinfection.

Answer: c) Worsening hypoxemia that can occur after starting antimicrobial therapy.

30. Which of the following is a common adverse effect of Amphotericin B that requires extensive pre-medication and monitoring?

• a) Infusion-related reactions (fever, chills, rigors) and nephrotoxicity.
• b) Severe headache.
• c) Peripheral neuropathy.
• d) Optic neuritis.

Answer: a) Infusion-related reactions (fever, chills, rigors) and nephrotoxicity.

31. Prophylaxis for recurrent oral or vulvovaginal candidiasis is:

• a) Recommended for all patients with a CD4 count < 200 cells/mm³.
• b) Not routinely recommended due to concerns about resistance and drug interactions.
• c) Accomplished with daily topical nystatin.
• d) Required for all HIV-positive individuals.

Answer: b) Not routinely recommended due to concerns about resistance and drug interactions.

32. A patient with HIV who is seropositive for Toxoplasma gondii should be counseled to avoid:

• a) Drinking tap water.
• b) Eating raw or undercooked meat and handling cat litter.
• c) Receiving vaccinations.
• d) Traveling by airplane.

Answer: b) Eating raw or undercooked meat and handling cat litter.

33. An HIV-positive patient is diagnosed with active tuberculosis. How should their ART and TB treatment be managed?

• a) ART should be delayed until TB treatment is complete.
• b) TB treatment should be delayed until the CD4 count is > 200.
• c) Both should be started, but ART is typically initiated within 2-8 weeks after starting TB therapy, with careful attention to drug interactions.
• d) The regimens can be started simultaneously on the same day without any concerns.

Answer: c) Both should be started, but ART is typically initiated within 2-8 weeks after starting TB therapy, with careful attention to drug interactions.

34. Secondary prophylaxis (maintenance therapy) for an opportunistic infection is indicated after:

• a) A patient has been exposed to the pathogen.
• b) A patient has been successfully treated for an acute episode of the OI.
• c) A patient’s CD4 count drops below a certain threshold.
• d) A patient requests it.

Answer: b) A patient has been successfully treated for an acute episode of the OI.

35. A patient on valganciclovir for CMV maintenance therapy should be monitored for which significant hematologic toxicity?

• a) Thrombocytosis
• b) Neutropenia
• c) Polycythemia
• d) Eosinophilia

Answer: b) Neutropenia

36. The treatment for esophageal candidiasis requires:

• a) Topical therapy only.
• b) Systemic antifungal therapy (e.g., oral or IV fluconazole).
• c) No treatment is necessary.
• d) A single dose of nystatin.

Answer: b) Systemic antifungal therapy (e.g., oral or IV fluconazole).

37. Which of the following is a key reason to rule out active TB before treating for latent TB infection (LTBI) in a person with HIV?

• a) The treatments are the same.
• b) To avoid undertreating active disease and promoting resistance.
• c) The diagnostic tests for LTBI are 100% specific.
• d) LTBI is more contagious than active TB.

Answer: b) To avoid undertreating active disease and promoting resistance.

38. Flucytosine is almost never used as monotherapy for cryptococcal meningitis because:

• a) It has too many side effects.
• b) Resistance develops rapidly when it is used alone.
• c) It is not effective against Cryptococcus.
• d) It is only available as a topical formulation.

Answer: b) Resistance develops rapidly when it is used alone.

39. A patient with a CD4 count of 180 cells/mm³ needs prophylaxis for:

• a) PJP only.
• b) PJP and MAC.
• c) PJP and Toxoplasmosis (if seropositive).
• d) MAC only.

Answer: a) PJP only.

40. The organism Pneumocystis jirovecii is classified as a:

• a) Bacterium
• b) Virus
• c) Fungus
• d) Parasite

Answer: c) Fungus

41. Which of the following is a common adverse effect associated with high-dose TMP-SMX therapy?

• a) Hypokalemia
• b) Rash, fever, and leukopenia
• c) Constipation
• d) Hypertension

Answer: b) Rash, fever, and leukopenia

42. A patient with AIDS presents with progressive neurological decline, and a brain MRI shows non-enhancing white matter lesions. This is suggestive of:

• a) HIV-associated neurocognitive disorder (HAND).
• b) Progressive Multifocal Leukoencephalopathy (PML) caused by the JC virus.
• c) Toxoplasmosis encephalitis.
• d) CNS Lymphoma.

Answer: b) Progressive Multifocal Leukoencephalopathy (PML) caused by the JC virus.

43. The only effective treatment for Progressive Multifocal Leukoencephalopathy (PML) is:

• a) High-dose acyclovir.
• b) Ganciclovir.
• c) Effective antiretroviral therapy to restore immune function.
• d) There is no effective treatment.

Answer: c) Effective antiretroviral therapy to restore immune function.

44. After successful treatment of an acute OI, when can secondary prophylaxis (maintenance therapy) generally be discontinued?

• a) Never, it is lifelong.
• b) After 6 months of ART, regardless of CD4 count.
• c) After a sustained increase in CD4 count above a specific threshold on ART.
• d) As soon as the patient feels better.

Answer: c) After a sustained increase in CD4 count above a specific threshold on ART.

45. Prophylaxis for recurrent herpes simplex virus (HSV) outbreaks in HIV patients is:

• a) Recommended for all patients.
• b) Not generally indicated unless outbreaks are frequent or severe.
• c) Done with topical creams only.
• d) A single, one-time dose of valacyclovir.

Answer: b) Not generally indicated unless outbreaks are frequent or severe.

46. What is the role of the pharmacist in managing OI prophylaxis?

• a) Identifying patients who meet the criteria to start or stop prophylaxis.
• b) Screening for drug interactions between OI medications and ART.
• c) Counseling patients on the importance of adherence.
• d) All of the above.

Answer: d) All of the above.

47. A patient with PJP has an arterial partial pressure of oxygen (PaO2) of 65 mmHg on room air. Is corticosteroid treatment indicated?

• a) No, because the PaO2 is not low enough.
• b) Yes, because a PaO2 < 70 mmHg is an indication for adjunctive corticosteroids.
• c) No, corticosteroids are contraindicated in PJP.
• d) Yes, but only if the patient has a sulfa allergy.

Answer: b) Yes, because a PaO2 < 70 mmHg is an indication for adjunctive corticosteroids.

48. Inhaled pentamidine for PJP prophylaxis is generally considered a second or third-line option due to:

• a) Its high efficacy and low cost.
• b) A lack of systemic absorption, leading to treatment failures and risk of extrapulmonary disease.
• c) Its convenient once-daily oral dosing.
• d) Its pleasant taste and smell.

Answer: b) A lack of systemic absorption, leading to treatment failures and risk of extrapulmonary disease.

49. For a patient with toxoplasmosis encephalitis, how long should acute therapy be continued?

• a) 1 week
• b) 2 weeks
• c) At least 6 weeks, followed by chronic maintenance therapy.
• d) Until the patient is afebrile for 24 hours.

Answer: c) At least 6 weeks, followed by chronic maintenance therapy.

50. An HIV-positive patient who is a healthcare worker should receive which of the following vaccinations?

• a) Live attenuated influenza vaccine (nasal spray).
• b) Annual inactivated influenza vaccine.
• c) They should not receive any vaccines due to their immune status.
• d) Only the MMR vaccine.

Answer: b) Annual inactivated influenza vaccine.