Lymphoma post-CHOP — neutropenia nadir day 10–14; G-CSF; cotrimoxazole
Neutropenia febrile — empiric broad-spectrum antibiotics within 1 hour (piperacillin/tazobactam or cefepime); risk-stratify with MASCC/CISNE score
Post-Splenectomy (OPSS Risk)
Overwhelming Post-Splenectomy Sepsis — rapidly fatal; caused by encapsulated organisms: S. pneumoniae (most common), H. influenzae type b, N. meningitidis
Lifelong penicillin V prophylaxis (or amoxicillin) — especially first 2 years and children
Assess exposure risk: HIV status of source; viral load; type of exposure
Follow-up HIV testing at 6 weeks, 3 months post-exposure
ART Adherence Counselling Guide▼
Adherence >95% is essential. Missing >1 dose/month risks viral rebound and resistance development.
1
Assess readiness & barriers: Ask open-ended questions about daily routine, work shifts, travel, side effects, stigma, mental health, substance use, family support
2
Educate on mechanism: Explain why consistent dosing maintains viral suppression; link U=U — undetectable = untransmittable (reduces stigma-related motivation barrier)
3
Practical strategies: Pillbox; phone alarm; link to daily habit (toothbrushing); private discreet pill storage if stigma concern; pill pouches for travel
4
Side effect management: TDF — renal monitoring; DTG — insomnia/neuropsychiatric (take in morning); EFV — vivid dreams/dizziness (take at bedtime, usually resolves 2–4 weeks)
5
GCC-specific considerations: Ramadan fasting — discuss dose timing with prescriber; prayer schedule alignment; avoiding disclosure to family/employer; expatriate documentation concerns
6
Missed dose: Take as soon as remembered UNLESS near next dose time (within <12h for once-daily) — skip missed; never double-dose
7
Monitoring: Viral load at 3–6 months; CD4 6-monthly until stable; LFTs, renal function, FBC at baseline and 3 months
8
Resistance counselling: Explain that partial adherence is worse than stopping — drug-resistance mutations can permanently limit future options
Opportunistic Infections (OIs) in Immunocompromised Patients
Oral (thrush): CD4 <300; white plaques (scrape off leaving erythema); treat with fluconazole 100–200mg × 7–14 days or nystatin suspension
Oesophageal (AIDS-defining): dysphagia, odynophagia; treat empirically with fluconazole 200mg × 14–21 days; endoscopy if no response; step-up to itraconazole or caspofungin
Immunoglobulin Replacement Therapy
Indications
Primary ID
XLA (Bruton's)
CVID
SCID (bridge to HSCT)
Hypogammaglobulinaemia NOS
Secondary ID
Post-rituximab hypogammaglobulinaemia
CLL with IgG <5g/L + recurrent infections
Myeloma with immune paresis + infections
Post-BMT (until immune reconstitution)
Non-ID Indications
ITP (high-dose IVIG)
Kawasaki disease
GBS / CIDP
Myasthenia gravis crisis
IVIG Infusion Rate Titration Protocol▼
CRITICAL: Always check IgA level before first infusion. IgA-deficient patients risk anaphylaxis with IgA-containing IVIG products. Use IgA-depleted product (e.g. Privigen) if IgA <0.07g/L.
Pre-Infusion Checklist
FBC, renal function (baseline eGFR — IVIG can cause osmotic nephropathy with sucrose-stabilised products)
IgA level — critical before first infusion
Confirm dose (typically 400–600mg/kg q3–4 weeks for replacement); batch number documentation
Premedication if previous reactions: paracetamol 1g + chlorphenamine 10mg IV 30 min before
IV access; ensure blood glucose normal (sucrose-containing products affect BM readings)
Anaphylaxis kit at bedside (adrenaline 0.5mg IM, antihistamine, hydrocortisone, O2)
Rate Titration (Standard Product)
Period
Rate
Duration
Action if Tolerated
0–15 min
0.5 mL/kg/h
15 min
Increase to next rate
15–30 min
1 mL/kg/h
15 min
Increase to next rate
30–60 min
2 mL/kg/h
30 min
Increase to next rate
60 min +
Up to 4–6 mL/kg/h
Remainder
Max rate per product SPC
Monitoring Frequency
Vital signs: before, at 15 min, 30 min, then every 30 min throughout infusion
First infusion: stay with patient for first 30 min; have resuscitation equipment nearby
Post-infusion observation: minimum 30–60 min
Adverse Reactions & Management
Reaction
Timing
Management
Headache, flushing, rigors
During infusion
Slow rate by 50%; paracetamol; usually resolves
Urticaria
During/after
Slow/stop; chlorphenamine IV; restart at lower rate
Anaphylaxis (IgA-deficient)
Within minutes
STOP; adrenaline 0.5mg IM lateral thigh; O2; IV fluids; call team
Haemolysis
24–48h post
FBC; check blood group; report to haemovigilance
Aseptic meningitis
24–72h post
Headache/meningism; CT/LP to exclude infective; NSAID; usually self-limiting
Q1. A 6-month-old Saudi male presents with recurrent Staphylococcus aureus and Aspergillus infections. Flow cytometry shows normal lymphocyte counts. The dihydrorhodamine (DHR) test is abnormal. What is the most likely diagnosis?
CGD is a phagocyte disorder caused by NADPH oxidase deficiency. Catalase-positive organisms (S. aureus, Aspergillus, Nocardia, Serratia) are characteristically affected. The DHR/NBT test is the diagnostic test of choice — absent oxidative burst confirms CGD. Normal lymphocyte counts rule out B- and T-cell disorders. CGD is more prevalent in GCC due to consanguinity.
Q2. An HIV-positive patient with a CD4 count of 45/µL reports 3 days of painless visual floaters and a "curtain" over the left eye. Which is the MOST appropriate initial nursing action?
CD4 <50 + painless floaters + field loss = CMV retinitis until proven otherwise. This is sight-threatening — retinal detachment can occur within days. Same-day ophthalmology is mandatory. Treatment is valganciclovir. Fluconazole is for candida, not CMV. Delay risks permanent vision loss.
Q3. You are preparing to administer IVIG to a patient with CVID. Pre-infusion IgA level returns as undetectable (<0.07 g/L). What is the MOST important action before proceeding?
IgA-deficient patients can have anti-IgA antibodies and develop severe anaphylaxis if given IgA-containing IVIG products. The correct response is to use an IgA-depleted product (e.g., Privigen, Octagam 10%). Anaphylaxis kit must be immediately available. Simply slowing the infusion rate does not prevent IgA-mediated anaphylaxis.
Q4. A 35-year-old woman 3 months post-splenectomy for traumatic rupture presents to the ED with fever 39.2°C, rigors and hypotension. She reports she was "not given vaccines after her operation." What is the PRIORITY management step?
This is Overwhelming Post-Splenectomy Sepsis (OPSS) — a life-threatening emergency with mortality up to 50–70%. Encapsulated organisms (S. pneumoniae most common) cause fulminant sepsis. Blood cultures must be taken but antibiotics must NOT be delayed awaiting results. IV cephalosporin (ceftriaxone 2g IV) must be given within 30 minutes. Vaccination can follow once the patient is stabilised.
Q5. An HIV-positive patient on TDF/FTC/DTG has been virologically suppressed (VL <50 copies/mL) for 18 months. He asks whether he can have unprotected sex with his HIV-negative partner. Which statement best reflects current evidence?
U=U (Undetectable = Untransmittable) is supported by the PARTNER1, PARTNER2, and Opposites Attract studies — zero transmissions occurred from virologically suppressed HIV-positive individuals. This applies to both heterosexual and MSM couples. This is a key counselling point that also reduces HIV stigma. Condoms are still recommended for STI prevention, but the patient should be counselled that sexual HIV transmission risk is effectively zero with sustained viral suppression.