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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 l.jpg
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


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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


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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


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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


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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


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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


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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


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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


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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)


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Who can test? have been undertaken?


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Who to test? have been undertaken?


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Rates of HIV-infected persons accessing have been undertaken?

HIV care by area of residence, 2007

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


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Who to test? have been undertaken?


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Who to test? have been undertaken?


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Who to test? have been undertaken?


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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


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Learning Points terminal presentation! If current guidelines used, HIV could have been diagnosed 6 years earlier

  • 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


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Key messages terminal presentation! If current guidelines used, HIV could have been diagnosed 6 years earlier

  • 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


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Also contains terminal presentation! If current guidelines used, HIV could have been diagnosed 6 years earlier

UK National Guidelines for HIV Testing 2008

from BASHH/BHIVA/BIS

Available from:

[email protected] or 020 7383 6345


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