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Case 11 71 year-old white male From the UK Had lived in London Retried to South Coast town Ex-smoker EtOH - 8 units day wine/spirits Unmarried, lived alone Case 11: June 2006 Admitted via Ophthalmology with: Probable HIV-related peripheral neuropathy

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case 11
Case 11
  • 71 year-old white male
  • From the UK
  • Had lived in London
  • Retried to South Coast town
  • Ex-smoker
  • EtOH - 8 units day wine/spirits
  • Unmarried, lived alone
case 11 june 2006
Case 11: June 2006

Admitted via Ophthalmology with:

  • Probable HIV-related peripheral neuropathy
  • Probable Pneumocystis jirovecii pneumonia
  • CMV retinitis

Sexual history:

    • Friend – long-term male partner
    • no UPAI 15 years

Initial investigations:

BAL: confirmed PCP

CD4 7; VL 200,000

case 11 pmh
Case 11: PMH

2000 Seen in Haematology for persisting lymphopenia

2000 Admitted with weight loss, watery diarrhoea

2001 Admitted with cerebellar infarct

2001 Seen in Neurology OPD (3 in London, 1 elsewhere)

for peripheral neuropathy - unknown cause

2003 Admitted with weight loss, OGD: oesophaghitis

2004 Admitted with fractured right neck of femur

  • lymphocytes 0.5 (1.3-3.5)
  • multiple mouth ulcers
  • candida on mouth swab

2005 “Recurrent LRTIs” throughout 2005

case 11 june 20064
Case 11: June 2006

Seen in Ophthalmology OPD:

  • vitreous detachment in left eye
  • 2/12 history of acute onset unilateral cloudy vision

OE:

  • retinal necrosis
  • features characteristic of CMV retinitis
  • SOB
  • Refractory to antibiotics from GP

Admitted to hospital

case 11 june 20065
Case 11: June 2006

Management:

  • Left vitrectomy and intraocular foscarnet
  • D/w Genitourinary Medicine team:

“What is the current treatment for non-HIV-related CMV retinitis?”

  • GUM team:

“Could this be HIV-related?”

Investigations:

  • Rapid strip HIV test reactive
  • Confirmatory 4th generation HIV test positive
case 11 june 20066
Case 11: June 2006

Further management:

  • CMV retinitis
    • Intraocular foscarnet
    • Initiated on Valgancyclovir 900mg po bd
      • 21/7 →maintenance
  • PCP
    • treated empirically with Co-trimoxazole, dose 120mg/kg bd
      • 21/7 →prophylaxis
  • HIV-related neuropathy
    • Prednisolone 60mg po od
    • Antiretroviral therapy initiated
case 11 june 20067
Case 11: June 2006

1 day prior to planned discharge:

  • Septicaemic shock
  • Died despite:
    • vigorous fluid resuscitation
    • broad spectrum antibiotic cover
    • ITU admission
    • ventilatory support
    • maximal inotropic support
  • Blood cultures grew Klebsiella terrigena
  • Cause of death
    • 1a: gram negative sepsis
    • 1b: multi organ failure
    • 1c: immunosupression 2°HIV
case 11 summary
Case 11: summary

2000 Haematology OPD, persisting lymphopenia

2000 Gen. med. admission, watery diarrhoea, weight loss

2001 General medical admission, cerebellar infarct

2001 Neurology OPD, peripheral neuropathy - unknown cause

2003 Gen. med. admission, weight loss - OGD: oesophagitis

2004 Fracture NOF, low lymphocytes, oral candida - recorded in ED notes “lives with male partner”

2005 General medical admission, LRTI – low lymphocytes

2006 Ophthalmology OPD “non-HIV related CMV retinitis”

2006 HIV diagnosed: PCP: CD4 7: VL 200,000

q at which of his healthcare interactions could hiv testing have been undertaken
Q: At which of his healthcare interactions could HIV testing have been undertaken?
  • When he was seen with persistent lymphopenia? (2000)
  • When he was admitted with watery diarrhoea? (2000)
  • When he was admitted with cerebellar infarct? (2001)
  • When he was seen for peripheral neuropathy? (2001)
  • When he was admitted with weight loss and oesophagitis? (2003)
  • When he was admitted with a fracture and disclosed living with male partner? (2004)
  • When he was admitted with recurrent LRTI? (2005)
  • When he was seen for “non-HIV-related CMV retinitis”? (2006)
slide12

Rates of HIV-infected persons accessing

HIV care by area of residence, 2007

Source: Health Protection Agency, www.hpa.org.uk

slide16

8 missed opportunities – 5 in ED - to diagnose HIV before terminal presentation! If current guidelines used, HIV could have been diagnosed 6 years earlier

2000 Haematology OPD, persisting lymphopenia

2000 Gen. med. admission, watery diarrhoea, weight loss

2001 General medical admission, cerebellar infarct

2001 Neurology OPD, peripheral neuropathy - unknown cause

2003 Gen. med. admission, weight loss - OGD: oesophagitis

2004 Fracture NOF, low lymphocytes, oral candida - recorded in ED notes “lives with male partner”

2005 General medical admission, LRTI – low lymphocytes

2006 Ophthalmology OPD “non-HIV related CMV retinitis”

2006 HIV diagnosed: PCP: CD4 7: VL 200,000

learning points
Learning Points
  • This patient had numerous investigations and 5 admissions over 6 years, causing him much distress and costing the NHS thousands of pounds
  • Some patients might not disclose risk factors for HIV on routine questioning in Outpatients even if the right questions are asked
  • Because of this the otherwise excellent medical teams looking after him did not think of HIV even when the diagnosis seems obvious with hindsight
  • A perceived lack of risk should not deter you from offering a test when clinically indicated
key messages
Key messages
  • Antiretroviral therapy (ART) has transformed treatment of HIV infection
  • The benefits of early diagnosis of HIV are well recognised - not offering HIV testing represents a missed opportunity
  • UK guidelines recommend universal HIV testing for patients from groups at higher risk of HIV infection
  • UK guidelines recommend screening for HIV in adult populations where undiagnosed prevalence is >1/1000 as it has been shown to be cost-effective
  • HIV screening should become a routine test on presentation of lymphopenia, PUO, chronic diarrhoea and weight loss of otherwise unknown cause
slide19

Also contains

UK National Guidelines for HIV Testing 2008

from BASHH/BHIVA/BIS

Available from:

[email protected] or 020 7383 6345

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