HIV and opportunistic infections

22 NEET-PG practice questions on HIV and opportunistic infections, part of General Medicine. The first 22 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Easy

   A 29-year-old man is diagnosed with HIV-1 at an ICTC. He has no opportunistic infection, CD4 count is 480 cells/µL and renal function is normal. Under NACO guidelines, which first-line ART should he start?

   1. ANo ART until the CD4 count falls below 350
   2. BZidovudine + lamivudine + nevirapine
   3. CTenofovir + lamivudine + dolutegravir
   4. DTenofovir + lamivudine + efavirenz

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   Answer: C · Tenofovir + lamivudine + dolutegravir

   India follows 'treat all': ART is offered to every person with HIV regardless of CD4 count, ideally within days of diagnosis. The preferred first-line regimen for adults is the single-pill combination TLD (tenofovir, lamivudine and dolutegravir), which is potent, well tolerated and has a high barrier to resistance. Early ART cuts illness and death, and an undetectable viral load stops sexual transmission.

   • A: CD4-based thresholds were dropped when India adopted treat-all.
   • B: Zidovudine and nevirapine are older drugs with more toxicity and are not preferred.
   • D: Efavirenz-based TLE was the earlier first-line regimen, now replaced by TLD.

2. Question 2 · Hard

   A 24-year-old man with HIV is in week 1 of treatment for cryptococcal meningitis with amphotericin B and flucytosine. His headache is worsening and he now has blurred vision, but he is alert with no focal deficit. Repeat lumbar puncture shows an opening pressure of 34 cm H2O; CT brain done before the tap showed no mass lesion or hydrocephalus. What is the next best step?

   1. ASwitch amphotericin B to high-dose fluconazole
   2. BAdd IV dexamethasone to reduce the raised pressure
   3. CGive oral acetazolamide to reduce CSF production
   4. DDrain CSF and repeat the lumbar puncture daily until pressure is normal

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   Answer: D · Drain CSF and repeat the lumbar puncture daily until pressure is normal

   Raised CSF pressure is common in cryptococcal meningitis because the fungus and its capsular polysaccharide block CSF outflow, and it causes much of the early death and blindness. When the opening pressure is 25 cm H2O or more with symptoms, CSF is drained at each lumbar puncture to bring the pressure down, repeated daily until stable. Steroids, acetazolamide and mannitol do not help and steroids increase mortality. Antifungal therapy continues unchanged.

   • A: The problem is pressure, not drug failure; fluconazole is weaker induction.
   • B: Dexamethasone increased deaths in cryptococcal meningitis trials.
   • C: Acetazolamide did not help and caused metabolic acidosis in trials.

3. Question 3 · Easy

   A 31-year-old woman with HIV is to be started on an abacavir-containing regimen because tenofovir is unsuitable for her kidneys. Which test should be done before the first dose?

   1. AHLA-B*15:02 genotyping
   2. BHLA-B*57:01 genotyping
   3. CCYP2C19 genotyping
   4. DG6PD enzyme assay

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   Answer: B · HLA-B*57:01 genotyping

   Abacavir causes a hypersensitivity reaction (fever, rash, gastrointestinal and respiratory symptoms) almost only in people who carry HLA-B*57:01. Screening for this allele before starting, and avoiding abacavir in carriers, has nearly abolished the reaction. A patient who has had the reaction must never be rechallenged, because re-exposure can cause fatal hypotension.

   • A: HLA-B*15:02 predicts carbamazepine-induced SJS/TEN in people of Asian descent.
   • C: CYP2C19 status affects clopidogrel activation, not abacavir safety.
   • D: G6PD testing is done before primaquine or dapsone, not abacavir.

4. Question 4 · Medium

   A 38-year-old man with untreated HIV, CD4 count 54 cells/µL, presents with headache, fever and right-sided weakness for 10 days. Contrast MRI shows three ring-enhancing lesions in the basal ganglia and at the grey-white junction, with surrounding oedema. Serum anti-Toxoplasma IgG is positive. What is the most appropriate next step?

   1. AAlbendazole with steroids for neurocysticercosis
   2. BWhole-brain radiotherapy for lymphoma
   3. CStereotactic brain biopsy before any treatment
   4. DEmpirical pyrimethamine, sulfadiazine and folinic acid

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   Answer: D · Empirical pyrimethamine, sulfadiazine and folinic acid

   Multiple ring-enhancing lesions in the basal ganglia and grey-white junction, with CD4 below 100 and positive Toxoplasma IgG, are typical of cerebral toxoplasmosis, a reactivation of latent infection. Empirical treatment with pyrimethamine and sulfadiazine (with folinic acid to protect the marrow) is started; cotrimoxazole is an alternative. Most patients improve clinically within 2 weeks; if not, primary CNS lymphoma is considered and biopsy is done.

   • A: Neurocysticercosis is not the leading cause of multiple ring lesions at this CD4 count.
   • B: Lymphoma is usually a single lesion, and its diagnosis is not assumed without tissue.
   • C: Biopsy is kept for lesions that do not respond to 2 weeks of empirical therapy.

5. Question 5 · Medium

   A 27-year-old man with newly diagnosed HIV (CD4 count 45 cells/µL) is being treated for cryptococcal meningitis with amphotericin B and flucytosine. He is improving, and CSF opening pressure is now normal. When should ART be started?

   1. A4-6 weeks after starting antifungal treatment
   2. BOnly after the CSF culture becomes sterile twice
   3. CWithin 48 hours of starting antifungal treatment
   4. DAfter 12 months of fluconazole maintenance

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   Answer: A · 4-6 weeks after starting antifungal treatment

   In cryptococcal meningitis, starting ART early (within the first 1-2 weeks) increased deaths in trials, mainly through IRIS in the closed space of the skull. Guidelines therefore defer ART for 4-6 weeks after antifungal therapy begins. This is unlike most other opportunistic infections, including pulmonary TB, where ART starts within 2 weeks.

   • B: Waiting for repeated sterile cultures is not the rule and needlessly delays ART.
   • C: Very early ART in cryptococcal meningitis raises mortality from IRIS.
   • D: A year of delay leaves the immune system unrepaired and risks new infections.

6. Question 6 · Medium

   A 30-year-old man has been on tenofovir, lamivudine and efavirenz for 3 weeks. He complains of vivid nightmares, dizziness and poor concentration, worst in the first hours after his bedtime dose. He has no fever, rash or jaundice. Which drug is responsible?

   1. ACotrimoxazole
   2. BEfavirenz
   3. CTenofovir
   4. DLamivudine

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7. Question 7 · Medium

   A 42-year-old woman with HIV who stopped ART a year ago comes to the eye OPD with floaters and blurred vision in her right eye for 2 weeks; there is no pain or redness. CD4 count is 28 cells/µL. Fundoscopy shows yellowish-white retinal necrosis with haemorrhages along the vessels. Which drug should be started?

   1. AOral valganciclovir
   2. BTopical prednisolone acetate
   3. CIV acyclovir
   4. DOral fluconazole

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8. Question 8 · Easy

   A 36-year-old truck driver with HIV, CD4 count 140 cells/µL, presents to the ART centre with painful swallowing for a week. He has white plaques on the palate and buccal mucosa that scrape off, leaving a red base. He is afebrile and eating soft food. What is the next best step?

   1. AUpper GI endoscopy with biopsy first
   2. BOral fluconazole for 2-3 weeks
   3. CClotrimazole troches for 1 week
   4. DOral acyclovir for 10 days

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9. Question 9 · Hard

   A 28-year-old man with HIV, not on ART, has had dry cough and breathlessness for 3 weeks. He is breathless on talking. Temperature 38.2 °C, respiratory rate 32/min, SpO2 86% on room air; ABG on room air shows PaO2 58 mmHg. Chest X-ray shows bilateral perihilar ground-glass shadowing, and LDH is 620 U/L. Induced sputum shows cysts on silver staining. Which treatment is most appropriate?

   1. AIV ceftriaxone with azithromycin
   2. BIV cotrimoxazole alone
   3. COral dapsone with trimethoprim
   4. DIV cotrimoxazole with oral prednisolone

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10. Question 10 · Hard

    A 30-year-old woman newly diagnosed with HIV at a district ART centre has a CD4 count of 72 cells/µL. She has no headache, fever, neck stiffness or confusion. Her serum cryptococcal antigen (CrAg) test, done as screening, is positive. What is the next step?

    1. ANo action, as she has no symptoms of meningitis
    2. BLumbar puncture to look for cryptococcal meningitis
    3. CRepeat serum CrAg after 4 weeks before deciding
    4. DStart fluconazole and ART today without further tests

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11. Question 11 · Easy

    A 40-year-old man with HIV and a CD4 count of 80 cells/µL has had watery diarrhoea and weight loss for 6 weeks. A modified Ziehl-Neelsen stain of stool shows large oval, acid-fast oocysts about 25 µm long. Which drug should be prescribed?

    1. ACotrimoxazole
    2. BNitazoxanide
    3. CMetronidazole
    4. DAlbendazole

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12. Question 12 · Medium

    A 45-year-old man on TLD for 3 years attends the ART centre for routine review. He feels well. Blood sugar is normal, but urine shows glucose 2+ and protein 1+. Serum creatinine has risen from 0.9 to 1.5 mg/dL, phosphate is 2.0 mg/dL (2.5-4.5) and there is a mild normal anion gap acidosis. Which drug is the most likely cause?

    1. ATenofovir (TDF)
    2. BDolutegravir
    3. CLamivudine
    4. DCotrimoxazole

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13. Question 13 · Medium

    A 35-year-old man with HIV and CD4 count 38 cells/µL is started on ART 2 weeks after treatment for Pneumocystis pneumonia. Consider these statements about immune reconstitution inflammatory syndrome (IRIS): 1. A low CD4 count at the start of ART increases the risk. 2. A short gap between treating the infection and starting ART increases the risk. 3. IRIS usually occurs within the first 3 months of ART. 4. IRIS means the virus is resistant and ART must be switched. Which statements are correct?

    1. A1, 3 and 4 only
    2. B1, 2 and 3 only
    3. C1, 2, 3 and 4
    4. D1 and 2 only

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14. Question 14 · Medium

    A 26-year-old woman has been on TLD for 14 months. Her first routine viral load, done at 12 months, was undetectable. Today's viral load is 4,800 copies/mL. She admits to missing doses during a family crisis. What is the next step?

    1. ASend genotypic resistance testing and stop ART meanwhile
    2. BEnhanced adherence counselling and repeat viral load after 3 months
    3. CRepeat the viral load next week with no other change
    4. DSwitch at once to a second-line regimen

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15. Question 15 · Medium

    A 37-year-old man on second-line ART with zidovudine, lamivudine and ritonavir-boosted atazanavir comes because his wife noticed his eyes look yellow. He is well. Total bilirubin is 4.1 mg/dL (direct 0.4), ALT 32 U/L, ALP normal, Hb 13.2 g/dL and reticulocytes 1%. What is the most likely explanation?

    1. AHaemolysis caused by zidovudine
    2. BAtazanavir inhibiting UGT1A1
    3. CAcute hepatitis B reactivation
    4. DDrug-induced cholestatic hepatitis

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16. Question 16 · Medium

    A 32-year-old man is newly diagnosed with HIV at an ICTC; his CD4 count is 310 cells/µL. On the four-symptom screen he has no cough, fever, weight loss or night sweats, and his chest X-ray is normal. He is to start TLD. Besides ART, what should be offered?

    1. ANo other drug until CD4 is repeated
    2. BTB preventive treatment
    3. CFull four-drug ATT for presumed TB
    4. DSputum culture before any further step

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17. Question 17 · Medium

    A 34-year-old man from Bihar is diagnosed with HIV and smear-positive, drug-sensitive pulmonary TB in the same week. CD4 count is 210 cells/µL. He has no headache or neck stiffness. He starts ATT today. When should ART be started?

    1. AWithin 2 weeks of starting ATT
    2. BAfter ATT is completed at 6 months
    3. COnly when the CD4 count falls below 200
    4. DAfter 8 weeks, when the intensive phase ends

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18. Question 18 · Easy

    At 11 pm a staff nurse in a district hospital pricks her finger with a hollow-bore needle used to draw blood from a patient known to have HIV. She washes the wound with soap and water. Consider these statements about post-exposure prophylaxis (PEP): 1. PEP should start as soon as possible, ideally within 2 hours. 2. PEP is not useful if started more than 72 hours after exposure. 3. The course lasts 28 days. 4. PEP should be delayed until the source patient's viral load is known. Which statements are correct?

    1. A1, 2 and 3 only
    2. B2, 3 and 4 only
    3. C1, 2, 3 and 4
    4. D1 and 3 only

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19. Question 19 · Hard

    A 35-year-old man from Imphal, Manipur, with HIV and a CD4 count of 22 cells/µL has had fever, weight loss and cough for a month. He has generalised lymph nodes, hepatosplenomegaly and many skin papules with a central umbilication on his face and upper trunk. Bone marrow aspirate shows small yeast cells with a central septum inside macrophages. What is the treatment of choice?

    1. AOral fluconazole for 8 weeks
    2. BIV amphotericin B, then oral itraconazole
    3. CIV ganciclovir, then oral valganciclovir
    4. DIV cotrimoxazole for 21 days

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20. Question 20 · Medium

    A 33-year-old woman has been on a zidovudine, lamivudine and nevirapine regimen for 4 months. She now has fatigue and breathlessness on exertion. Hb is 7.2 g/dL, MCV 112 fL, WBC 3,600/µL and platelets 1,90,000/µL. Serum B12 and folate are normal. What is the most likely cause of her anaemia?

    1. AHaemolysis induced by nevirapine
    2. BPure red cell aplasia from parvovirus B19
    3. CMarrow suppression by zidovudine
    4. DAnaemia of chronic disease due to HIV

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21. Question 21 · Hard

    A 31-year-old woman with HIV (baseline CD4 count 62 cells/µL) and drug-sensitive TB lymphadenitis started ATT, and 2 weeks later TLD. Three weeks after starting ART she has fever and her cervical nodes have enlarged and become tender, with one now fluctuant. She was improving before ART. Her viral load has fallen from 2,10,000 to 900 copies/mL, and CBNAAT on node aspirate shows no rifampicin resistance. What is the best management?

    1. AContinue ATT and ART; aspirate the node and give prednisolone
    2. BSwitch ART to a second-line protease inhibitor regimen
    3. CSwitch to an MDR-TB regimen for presumed resistance
    4. DStop ART until the nodes settle, then restart it

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22. Question 22 · Medium

    A 29-year-old woman on TLD (tenofovir, lamivudine, dolutegravir) for 2 years, with an undetectable viral load, is diagnosed with pulmonary TB and started on a rifampicin-based regimen. What change should be made to her ART?

    1. ASwitch dolutegravir to efavirenz for the ATT course
    2. BAdd an extra 50 mg dolutegravir 12 hours after TLD
    3. CStop ART until rifampicin is completed
    4. DContinue TLD unchanged and check viral load monthly

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