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HIV Case Presentation

HIV Case Presentation. Dr. Cho Cho Thein PHC Physician, Ebeye CHC RMI. Patient [H03]. Ebeye, Marshall Islands. Clinical History. 1yr 6mths old Marshallese boy Born in Santo Island (Home Delivery) with no perinatal problems encountered

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HIV Case Presentation

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  1. HIV Case Presentation Dr. Cho Cho Thein PHC Physician, Ebeye CHC RMI

  2. Patient [H03] Ebeye, Marshall Islands

  3. Clinical History • 1yr 6mths old Marshallese boy • Born in Santo Island (Home Delivery) with no perinatal problems encountered • At the age of 4 months the child started to develop non-productive cough with undocumented fever, poor appetite and failure to thrive • He was admitted to Ebeye hospital for 3 times in 4 months period.

  4. CBC showed anemia and thrombocytopenia and transfused with whole blood(15cc/kg). • CT scan of the abdomen showed hepatosplenomegaly with mesenteric and retroperitoneal adenopathy suggestive of Lymphoma • The patient was then transferred to St. Luke’s Hosptal, PI for further evaluation and management.

  5. First admission • DOA: 8/19/08 • DOD: 9/2/08 • Admission Dx: Community Acquired Pneumonia • D/C Dx: Community Acquired Pneumonia in moderate respiratory distress Intestinal Amoebiasis with ileus Cellulitis (R)Thigh

  6. 2nd Admission • DOA: 9/27/08 • DOD: 10/2/08 • Admission Dx: AGE with some Dehydration • D/C Dx: AGE Scabies Malnutrition Anaemia

  7. 3rd Admission • DOA: 11/06/08 • Admission Dx: Bronchopneumonia Failure to thrive Mass Abdomen vs Neuroblastoma Referred to Majuro Hospital: 11/19/08 D/C Dx: Lymphoma

  8. Readmission on 12/2/08 • Dx: Lymphoma • For Lymphadenopathy • Diarrhea with no dehydration • Hepatosplenomegaly

  9. Off- island referral( St. Luke’s Hospital, PI) • DOA: 1/10/09 • DOD:4/30/09 • Initial impression: Recurrent Pneumonia , Lymphoma • Final Dx: Epstein Barr virus Infection AIDS Gastro-esophageal Reflux Disease Recurrent Bronchitis secondary to microaspiration of gastric reflux and/or reflux Bronchospam secondary to GERD Recurrent Diarrhea secondary to AIDS

  10. Personal History • Developmental History: - can sit alone - can stand with support - can transfer objects from one hand to hand, can hold bottle - can do close-open hand movement • Personal and Psychsocial History: -a cheerful cooperative boy with development delay and is severely malnourished.

  11. Immunization History: Received BCG; HepB1,2,3; DPT 1,2,3; OPV 1,2,3 and HiB 1,2 • Nutrition History: mixed feeding since birth, supplementary feeding started at 6 months of age. Primary care taker is mother and aunty • PMH: 3 previous admissions at Ebeye hospital -Aug 08: Bronchopneumonia and abdominal distension secondary to ileus -Sept 08: AGE and ileus -Nov 08: Bronchopneumonia, AGE, Failure to thrive

  12. Family History (+) DM- Mother (-) Hypertension (-) Cancer (-) Bronchial asthma (-) HIV- Mother- 1st prenatal booking (9/5/07) As the patient tested positive, the mother was also tested for HIV at St. Luke’s Hospital. ELISA test done twice and revealed negative results.

  13. Physical Examination (5/26/09) • Vital Signs Active, not in distress B.P 90/60 HR: 120bpm RR 40cpm Temp 98.6F -Ht 67 cm -Wt 9kg -Wasting • Pink palpebral conjunctivae, anicterus sclerae • Tonsils not enlarged

  14. -(+) Bilateral cervical and submandibular Lymphadenopathy • Clear breath sounds with good air entry • (-) Hepatosplenomegaly • (-) skin rashes • (-) oral thrush

  15. Blood Chemistry

  16. Clinical Serology & Immunology

  17. Clinical Serology & Immunology

  18. Clinical Serology & Immunology

  19. Urinalysis

  20. Primary Immunodeficiency Panel 1 Report • Flow Cytometry Clinical Report

  21. Primary Immunodeficiency Panel 1 Report

  22. HIV ELISA test + • Confirmatory test: Western Blot + • HIV DNA PCR + • Mother was tested for HIV for two times revealed negative • Donor from Ebeye was found out to be negative

  23. Hematology Data

  24. Blood Type - O Rh positive

  25. Fecalysis

  26. Microbiology Cryptosporidium and Giardia detection by Immunoflorescence Microscopy result: (03/14/09) stool specimen • 2 samples were analyzed -With the first sample , 1 out of 3 slides was positive for Cryptosporidium only -With the second sample, all sides were negative for both Giardia and Cryptosporidium • Clostridium difficile antigen test (03/16/09 & 04/18/09) Clostridium difficile Toxin A = Negative

  27. Microbiology • Blood Culture -1/19/09:No growth after 5 days; Incubation : Aerobically -3/2/09: No growth after 3 days; Incubation Aerobically - 04/14/09: No growth after 5 days; incubation Aerobically • Gastric Aspirate for AFB- Negative (1/13 & 1/14/09) • Gastric Aspirate for Mycobacterium tuberculosis detection result (01/23/09) -PCR result : Negative

  28. Surrogate Markers

  29. Diagnostic Radiology • X-RAY Hand: Patient’s chronological age is one yr and one month old. Delayed bone aging based on Greulich and Pyle chart compatible with less than one yr. • KUB: Soft tissue density in the upper hemi abdomen due to hepatosplenomegaly. Non Obstructive gas pattern. • CXR: Reflects Viral or Reactive Airway Disease • UGI series: Two Episodes of High Grade Gastro esophageal reflux • CXR: Normal Chest

  30. Diagnostic Radiology • CXR: Hypoaerated Lungs without focal consolidaton • CT Scan: Enlarged Paratracheal and confluent abdominal lymph nodes with associated hepatospelnomegaly. This could reflec a neoplastic process such as lymphoma. However such as mycobacterial infection could present similar imaging findings. Histological correlation is recommended. Bowel wall thickening but without sign of obstruction. Bilateral upper lobe subsegmental atelactasis

  31. Initial HAART • Starts with Nevirapine suspension and Stavudine-Lamivudine : Fever , generalized rash • Switch to Efavirenz 50mg/cap 2 caps once a day • Lamivudine –Stavudine 150mg/30mg/tab, ¼ tab every 12 hrs • Cotrimoxazole suspension 200mg/40mg/5ml, 3ml bid thrice a week

  32. Outcome of HIV Clinical Training Clinical: • Universal precaution protocol and practice is in place in all clinical areas • HIV program has well established the prevention and treatment • Able to discuss sexual risk behaviors with clients, colleagues and community • Risk assessment of HIV and STD is done to all persons for HIV testing • We have adequate supply of condoms but user rate is still low • We are now much confident in taking case history, counseling, giving care, doing physical examination and treatment to HIV patients after attending clinical training on island and off island.

  33. Capacity Building and Systems outcome • We are able to provide HIV clinical training to all health care providers and new recruits every year. • National HIV protocol is in place. • Hospital is able to provide clinical care and availability of ARV is still limited and medication for all OI is not available. • Routine STD and HIV screening are provided • Access to computer: Replacement of computers for our program is very slow and we have only one LCD projector in our hospital. • For the time being we do not have Internet access at the hospital to all providers • Our HIV team is able to provide the training

  34. Prevention Strategies • We are able to describe and implement prevention strategies on individual, group and community level. • We have certified HIV counselors and they involve in counseling and referral services. Able to describe the importance of informed consent and confidentiality of HIV • Clinicians and HIV program staff can prescribe common treatment for prevention of PCP Personal Growth • Able to apply treatment and prevention care • Prevention of perinatal transmission protocol is in place • Core clinician understood proper infant feeding measures for HIV positive mothers

  35. Able to identify OI commonly associated with HIV/AIDS • Reliable access to ARV medication • Able to identify at least 3 common combination drug therapies for HIV treatment • Can identify some medication side effects associated with HAART medication • We follow CDC and OSSHHM clinical treatment guidelines • Core team trained in HIV care • PEP protocol is in place • Access to HIV treatment experts for clinical consultations • Able to identify and practice good patient relationships • Low usage of condom

  36. Able to provide HIV pre and post test counseling • Sufficient knowledge about HIV transmission, prevention, treatment regimen among core team, able to do assessment, physical exam and able to work up a newly diagnosed HIV patient. • Reliable access to ELISA and Western blot test for HIV. Specimens are sent to Hawaii DLS. (CD4 & VL tests) and HIV resistant tests.

  37. Kommol Tata!

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