Case 7

1. Case 7 23 year-old woman From former Soviet state Arrived in UK October 2008 Living in London

2. Case 7: November 2008 Presented to ED of hospital 1 4-day history of: • Fever • Sweats • Dry cough 2-day history of: • Pleuritic right-sided chest pain • Rigors • Shortness of breath

3. Case 7: November 2008 On admission to hospital 1: • Unwell • Right pleural rub • Bronchial breathing at Right base • PaO2 = 9.5 kPa (on air) • CXR = Right lower lobe pneumonia • Blood cultures confirmed Strep. pneumoniae

4. Case 7: November 2008 • Given benzylpenicillin/clarithromycin → recovered • Persistently elevated ALT (=71, Normal<50) • USS normal • Hepatitis A, B, and C serology negative • Seen for follow up in OPD, 2 weeks after • Hospital discharge. • LFTs now normal • Was well → no further follow-up

5. Case 7: April 2009 Re-presents to ED of hospital 1 3-day history of: • Cough with rusty sputum • Fever with sweats • Chills • Headache • Reported 8kg weight loss over previous 5 months

6. Case 7: April 2009 OE: • Signs of Left upper lobe consolidation • CXR = L upper lobe pneumonia • Sputum/blood culture = negative • Peripheral blood WBC = 12.3 x109/L • Treated empirically for bacterial pneumonia • → recovered • Patient DNAd follow-up appointment

7. Case 7: June 2009 • Moved to new job • Now registered with GP • Visits GP - reports she is unwell, lethargic • GP finds nil abnormal on examination • Blood tests: Monospot negative,Hb 9.9 g/dl, MCV normal, ESR 50 mm/hr • Referred by GP to Haematology OPD of hospital 2 BUT before being seen in OPD…

8. Case 7: July 2009 Brought to ED of hospital 2 by her employer OE: • Severely unwell • Cyanosed • Tachypnoeic (resp rate = 26/min) • Pyrexial, T = 38.4 degC • Also - ED ST2 notices oral candida and oral hairy leukoplakia on tongue

9. Case 7: July 2009 Investigations: • PaO2 (on air) = 6.9 kPa • CXR = marked bilateral infiltrates • ST2 queries underlying HIV infection - begins empirical therapy for PCP • Patient transferred from ED to ICU

10. Case 7: July 2009 On ICU: • With supplemental oxygen (FiO2 = 60%) → • Better oxygenated • ICU Consultant offers patient an HIV test • Offer accepted • HIV test is positive • CD4 count = 100 cells/µl • Viral load = 380 000 copies/ml

11. Case 7: July 2009 • PCP treatment continued(high-dose co-trimoxazole and methyprednisolone) → improvement in oxygenation • On day 4 of ICU admission patient deteriorates, with worsening oxygenation following fibreoptic bronchoscopy and BAL (confirms PCP) • CXR excludes pneumothorax • CPAP given for 3 days→ patient improves • Discharged to general ward after 8 days on ICU • Began ARVs after 14 days of PCP therapy → continued improvement • Discharged from hospital on day 19

12. Case 7: summary Nov 2008 Admitted, PUO, severe bacterial pneumonia, (negative Hepatitis A, B and C serology) April 2009 Admitted, recurrent bacterial pneumonia, weight loss June 2009 Registered with GP June 2009 Seen by GP with lethargy, anaemia and raised ESR July 2009 Admitted, respiratory distress HIV diagnosed: severe PCP: CD4 100, VL 380,000 Inpatient 19 days Includes 8 days on ICU

13. Q: At which of her healthcare interactions could/should HIV testing have been performed? • When she first presented with severe bacterial pneumonia? • When tests for viral hepatitis were performed? • When she re-presented with bacterial pneumonia and weight loss? • When she registered with a GP? • When she presented to GP with lethargy and was found to have anaemia and a raised ESR? • Should she have been referred to GUM to see a trained counsellor before HIV testing?

14. Who can test? Who can test?

15. Who to test?

16. Who to test?

17. Who to test? 2008 Report on the global AIDS epidemic HIV prevalence (%) in adults (15–49) in Eastern Europe and Central Asia, 2007

18. Who to test?

19. Rates of HIV-infected persons accessing HIV care by area of residence, 2007 Source: Health Protection Agency, www.hpa.org.uk

20. 4 missed opportunities! If current guidelines had been followed, HIV could have been diagnosed 9 months earlier Nov 2008 Admitted, PUO, severe bacterial pneumonia, (negative Hepatitis A, B and C serology) April 2009 Admitted, recurrent bacterial pneumonia, weight loss June 2009 Registered with GP June 2009 Seen by GP with lethargy, anaemia and raised ESR July 2009 Admitted, respiratory distress HIV diagnosed: severe PCP: CD4 100, VL 380,000 Inpatient 19 days Includes 8 days on ICU

21. Learning Points • This patient came from an area of high HIV prevalence, but was not offered an HIV test in several contacts with healthcare services • This patient had numerous investigations including 3 admissions and an ITU stay, causing her much distress and costing the NHS thousands of pounds • Because of her nadir CD4 of 100 she has an increased risk of potential problems despite control of her HIV now • A perceived lack of risk should not deter you from offering a test when clinically indicated

22. 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 screening for HIV in adult populations where undiagnosed prevalence is >1/1000 as it has been shown to be cost-effective • UK guidelines recommend universal HIV testing for patients from groups at higher risk of HIV infection • HIV screening should be a routine test on presentation of bacterial pneumonia, and PUO, anaemia or weight loss of otherwise unknown cause

23. Also contains UK National Guidelines for HIV Testing 2008 from BASHH/BHIVA/BIS Available from: enquiries@medfash.bma.org.uk or 020 7383 6345