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Case Presentation. Brandon White, BSN, RN, PHN Marion County Public Health Department Northwest District Health Office. Chapters. Chapter 1: One Day on NOD… Chapter 2: The Initial Visit Chapter 3: The Hospital Admission Chapter 4: The HIV Diagnosis Chapter 5: Early Challenges
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Case Presentation Brandon White, BSN, RN, PHN Marion County Public Health Department Northwest District Health Office
Chapters • Chapter 1: One Day on NOD… • Chapter 2: The Initial Visit • Chapter 3: The Hospital Admission • Chapter 4: The HIV Diagnosis • Chapter 5: Early Challenges • Chapter 6: Family Challenges • Chapter 7: The Work Friend
Chapters (cont.) • Chapter 8: The New Apartment • Chapter 9: Additional Challenges • Chapter 10: Contact Investigation • Chapter 11: Updates • Chapter 12: Recognition
One Day on NOD… • Client’s sister visited NWDHO in late October 2017 during Nurse of the Day (NOD) clinic hours. • Sister had fallen out of contact for LTBI treatment and we discussed restarting treatment. • Sister was agreeable, then asked, “Can you do for my sister [client] what you did for me?”.
One Day on NOD… (cont.) • Client arrived in the United States from Honduras in July 2017 with a cough and had deteriorated since. • Client was released from “the immigration hospital” in Texas in July 2017. • “How can I contact her to further evaluate?” “She’s actually in the car outside right now.”
One Day on NOD… (cont.) • Client is pleasant 21-year-old Spanish-speaking female. • Symptoms? • Appetite loss (“I only eat because I have to.”) • Chest pain upon inhalation • Pain in her neck, back • Chills, fevers, night sweats • Prolonged productive cough • Fatigue • Occasional emesis with bright red blood in the AM
One Day on NOD… (cont.) • She was agreeable to a home visit the next morning for further evaluation and TB follow-up. • Lives with her sister, brother-in-law, 12-year-old nephew, and 12-month-old nephew. • Client had not been seen by a doctor since arriving and was wary of the hospital.
The Initial Visit • I obtained a TB health history. • No PPD information from Texas, but reported a CXR (“They didn’t tell you what the results were.”). • Client said “immigration doctors” told her to F/U with TB doctors and that she was “weak from my immune system”—said she was released to Indiana.
The Initial Visit (cont.) • Reported fevers and night sweats that began in Honduras in April 2017 before the cough developed in July 2017. • Reported being underweight and anemic in Honduras, which led to hospitalization in June 2017 for a blood transfusion. • Reported she broke her leg in January 2014 and had a screw placed in her right femur.
The Initial Visit (cont.) • Denied a history of contact with active TB, but her sister said a family friend died of TB and client could have been exposed through contact with her. • The sister could not provide a date for when the friend had TB, but said she died approximately four years ago and actually she was uncertain if it was from TB or other causes.
The Initial Visit (cont.) • During the interview, the client excused herself to the bathroom and I heard coughing and retching. • Sister said “she practically vomits phlegm” and “takes a long time in the bathroom”. • Client returned to the interview and confirmed she was coughing up phlegm.
The Initial Visit (cont.) • Physical assessment: • BP 90/60 • HR 102 • Temp. 101.6 F • RR 16 • Unable to auscultate breath sounds because client was unable to inhale deeply without sharp pain. • Bilateral enlarged cervical lymph nodes that were painful to light touch.
The Initial Visit (cont.) • She also reported dizziness and syncope in the morning when getting out of bed. • I placed a PPD and provided sputum canisters.
The Initial Visit (cont.) • I strongly advised client to go to the ED. • Client was still wary. • I offered an appointment three days in the future at the Tuberculosis and Refugee Clinic, but told her she would likely be admitted anyway at that time. • Client relied on her sister for transportation—sister agreed to take client to the ED.
The Hospital Admission • The first two days (end of October 2017): • Hospital-obtained sputums were smear negative times three. • CXR was normal. • CT was pending PCR of sputums. • HIV test was positive; CD4 count of 30. • TB? Fungal? Lymphoma? Acute HIV?
The Hospital Admission (cont.) • The third day (end of October 2017): • I visited and read PPD result at the hospital as positive with a 17 mm induration. • Client was very upset about HIV diagnosis (more on that later). • One of client’s sputa was PCR positive—confirmed TB case. • Two of three were eventually culture positive.
The Hospital Admission (cont.) • The third day cont. (end of October 2017): • CT obtained due to the PCR positive sputum. • “Centrally hypodense—likely necrotic—lymph nodes” • “Tree-in-bud opacities” • RIPE initiated. • FNA of lymph nodes performed. • No MTB growth.
The Hospital Admission (cont.) • The remaining days (early November 2017): • Client’s symptoms improved while on RIPE. • ARV therapy was planned. • Client was released to her sister’s home after 14 days of RIPE at the hospital. • MCPHD would administer RIPE after release.
The HIV Diagnosis • Client was understandably distraught with the HIV diagnosis—but—was she already aware she had HIV? • Client was cooperative with MCPHD and the hospital, but she was very guarded and not forthcoming about her history.
The HIV Diagnosis (cont.) • Initially, she was shocked she was HIV positive. How? • Slowly, more details emerged. • Lived in an orphanage. • Likely history of sexual assault. • Diagnosed at 12 and took ARVs until she was 18. • Stopped ARVs because she thought the virus was no longer in her body.
The HIV Diagnosis (cont.) • Concern for immune reconstitution inflammatory syndrome (IRIS) after beginning ARVs and/or after improvement from TB treatment.
Early Challenges • Client missed her first F/U appointment with ID two days after release. • She eventually made it to a rescheduled ID appointment and was prescribed her ARVs, which she would not pick up. • She told me she did not want to wait at the pharmacy for them because it was too long. • Still wary of the hospital.
Early Challenges (cont.) • Initially, I called her ARV refills in and picked them up. • Now, she calls them in and I pick them up—progress!
Family Challenges • The very next day after release, the client missed her first non-hospital RIPE dose. • Client and sister would not answer the phone. • I made a home visit and only client’s nephew was home—client was at work! • Reminder: Client’s CD4 count was 30; she had not started ARVs; only 14 doses of RIPE; just out of the hospital.
Family Challenges (cont.) • Within days of release and beginning work, client developed fevers, headaches, and leg pain. (IRIS?) • I strongly advised returning to the hospital, but she would not go. • She began to feel better and returned to work.
Family Challenges (cont.) • Client was adamant about working, despite recommendations she rest until she started ARVs and her CD4 count increased. • Why so adamant about work given her serious health concerns?
Family Challenges (cont.) • There was a falling out between client and her sister over a significant debt. • Sister accepted a $10,000+ loan from an agency that preys upon people detained by ICE to bond client out. • Sister owed $400+ per month and demanded client work to help pay it down.
Family Challenges (cont.) • Client’s TB and HIV diagnoses were also sources of anger for the sister. • Sister became pregnant after client’s hospital admission, then experienced a miscarriage—high emotions in the family. • Client left her sister’s home unexpectedly and stayed elsewhere.
The Work Friend • After the family fallout, client was staying with a work friend who lived in a different district. • The friend was male and there was great concern for sexual activity. • SDHO assisted with her case management. • This occurred in December 2017 (Merry Christmas to us!).
The Work Friend (cont.) • Eventually, client expressed concerns about her safety. • The work friend and others drank often. • Client noticed a gun in the home. • Client and sister had reconciled and sister was helping her find an apartment and a roommate.
The New Apartment • Client moved into an apartment with her sister’s friend and the friend’s child. • Her mood and affect improved drastically and it improved her relationship with her sister. • She still lives there, although she is searching for a new roommate. • The previous roommate “met a boy and went to Kansas with him”.
Additional Challenges • Client has visited OB/GYN twice for STI F/U. • She denies sexual activity, but I have my doubts. • Constant IRIS concerns. • She presented to the ED in December 2017 with right-sided ear and head pain, but left AMA after they wanted to admit her—she improved on her own again. • Keeping appointments.
Additional Challenges (cont.) • Fear of deportation. • The loan agency made her take a monitoring bracelet. • She believes she could be taken by ICE if she is in the hospital for prolonged periods of time. • Medical bills. • MCPHD and hospital social workers have been working with client to obtain financial assistance. • She receives her ARVs at no cost.
Additional Challenges (cont.) • Client is compliant with her ARVs, but I have been working to get her to take ownership of obtaining them. • TB treatment duration could increase from six months to nine months or more if she stops taking the ARVs. • Client drives without a license.
Additional Challenges (cont.) • She can be aloof and miss DOT because she stays at other places. • Zoom video-based DOT has improved compliance. • She will not tell me she is actually at her sister’s place of business or her sister’s house until I am already at her apartment.
Contact Investigation • Brother-in-law: • First round PPD was positive—has an upcoming appointment with MCPHD Tuberculosis and Refugee Clinic. • Sister: • Already a positive reactor with a history of incomplete LTBI treatment. • Referral has been sent to PCP for new CXR; sister has been wishy-washy about new LTBI F/U.
Contact Investigation (cont.) • 12-month-old nephew: • First and second round PPDs were negative. • CXR was negative. • Completed window treatment. • 12-year-old nephew: • First round PPD was positive. • CXR was negative. • Currently receiving LTBI treatment via DOPT.
Contact Investigation (cont.) • Sister’s brother-in-law: • First round PPD was positive—has an upcoming appointment with MCPHD Tuberculosis and Refugee Clinic. • Family of sister’s brother-in-law: • First round PPDs on wife and four children were negative. • No children under the age of five.
Updates • Client culture converted on her second set of sputa obtained by MCPHD after her release from the hospital. • CD4 count has remained <50, although her viral load has decreased. • Stable condition—no TB symptoms or IRIS.
