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CASE 4. 67 yo man HIV+ 1991 Hypertensive CD4 on diagnosis 110/7% AZT initiated soon after diagnosis. CASE 4. Antiviral History. CASE 4. 2011 Referred for 2 distinct episodes (2008, 2011) of 5kg weight loss/profound fatigue and pancytopenia lasting 4-8 weeks each time. CASE 4. CASE 4.

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case 4
CASE 4
  • 67 yo man
  • HIV+ 1991
  • Hypertensive
  • CD4 on diagnosis 110/7%
  • AZT initiated soon after diagnosis
case 41
CASE 4

Antiviral History

case 42
CASE 4

2011

  • Referred for 2 distinct episodes (2008, 2011) of 5kg weight loss/profound fatigue and pancytopenia lasting 4-8 weeks each time
case 44
CASE 4

2011

CT abdomen

  • normal liver
  • Spleen 16 cm
  • No nodes
  • Spleen size unchanged from 2004 U/S

CT chest

  • normal
case 45
CASE 4

2011

Bone MarrowAspirate/Biopsy

  • Normal progenitors for all cell lines with no evidence of malignancy
  • Compatible with peripheral destruction/sequestration
case 46
CASE 4

2011

  • Noted that both episodes of constitutional symptoms occurred in temporal relationship to the initiation/reinitiation of Eprosarten therapy for hypertension
    • This medication was discontinued without further recurrence of symptoms over the next 2 years
case 47
CASE 4

2011-13

  • Blood counts recovered though platelets remained lower than previous
case 49
CASE 4

2012

  • Required a laparoscopic cholecystectomy and intra-operatively liver noted to be “coarse/nodular”
case 410
CASE 4

No ETOH – significant previous history x 20 yrs HCV RNA/HBV DNA (-)

secondary liver disease workup (-)

case 411
CASE 4
  • Fibroscan done…. 32.8 kpa!
  • U/S
    • No varices
    • +Ascites
    • Liver 18.7 c.m/nodular contour
    • Spleen 18.9 cm
    • Normal portal/hepatic veins
case 412
CASE 4

Transjugular liver biopsy performed

  • F2-3 scarring from steatohepatitis
  • Venous/sinusoidal pressures compatible with nodular regenerative hyperplasia or non cirrhotic portal hypertension
  • OGD…no varices
  • Ascites managed with diuretics
case 413
CASE 4

Take home message…

  • Low platelets, which have a very long differential diagnosis in the context of HIV, can be a clue to occult severe liver disease…ie. cirrhosis with portal hypertension, or far more rarely, non cirrhotic portal hypertension
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