CASE PRESENTATION DR F J MUGALA MUKUNGU PHYSICIAN KATUTURA STATE - - PowerPoint PPT Presentation

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CASE PRESENTATION DR F J MUGALA MUKUNGU PHYSICIAN KATUTURA STATE - - PowerPoint PPT Presentation

May 27, 2023 967 likes •1.54k views

CASE PRESENTATION DR F J MUGALA MUKUNGU PHYSICIAN KATUTURA STATE HOSPITAL 25-03-2017 ROOF OF AFRICA CASE PRESENTATION MR T.R DOB 1983.03.20 AGE 33 DOA-1 29.07.16 DOD- 16.08.16 DOA-2 22.08.16 DOD- 6.09.16 CASE PRESENTATION

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CASE PRESENTATION

DR F J MUGALA –MUKUNGU

PHYSICIAN KATUTURA STATE HOSPITAL 25-03-2017 ROOF OF AFRICA

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CASE PRESENTATION

MR T.R DOB 1983.03.20 AGE 33 DOA-1 29.07.16 DOD- 16.08.16 DOA-2 22.08.16 DOD- 6.09.16

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CASE PRESENTATION

  • New HIV Diagnosis at the time of

Admissions

  • Complaining of Fever, dry Cough and

Shortness of Breath.

  • He was started on Efavirenz /Tenofovir/

Emtricitabine (Teevir) and Purbac 960

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Social History

  • Single
  • Employment –Available
  • Alcohol Consumption - High
  • Smoker
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Examination

Critically ill High Temperature 40 0C High Respiratory rate 35/min Saturation 94% on 5L oxygen at weight 65.0 Kg Oedema +++

  • ral Candida

Cheilosis

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Examination

Respiratory System Clear Clear Abdomen Distended Hepatomegaly CNS well oriented Clear Terminal neck Stiffness

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LABORATORY RESULTS AVAILABLE

WCC was normal CD4 15 HB 5.0 Platelet 220 Urea 10.8mmols/L Creatinine 140µmoLs/L CRP- 300mg/L Liver Function : ALP is elevated 327

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LABORATORY RESULTS AVAILABLE

GGT elevated 445 IU/L ALT elevated 87 IU /L AST elevated 241 IU /L LDH – 727

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Chest Xray taken on 23/07/2017 Normal

NORMAL

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Question

What is the cause of Fever ? What is the Cause of Anaemia? What is the Cause of Abnormal Liver Enzymes?

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Question

What is the cause of Fever ?

  • 1. Sepsis
  • 2. IRIS
  • 3. PCP,
  • 4. TB
  • 5. Lymphoma
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Question What is the cause of Fever ?

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Question

What is the cause of Anemia ?

  • 1. Blood Loss
  • 2. Sepsis
  • 3. Disseminated Infection –Bone marrow

infiltration

  • 4. Medication AZT
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Question

What is the cause of Anemia ?

  • 1. Parvovirus Infection
  • 2. TB,
  • 3. Fungal –candida-malnutrition
  • 4. Malabsorption of Vitamin B12
  • 5. Vitamin deficiencies due to severe

Alcohol use

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Question

What is the cause of Abnormal Liver Enzymes ?

  • 1. Ethanol Use
  • 2. Hepatitis B
  • 3. Disseminated Tuberculosis
  • 4. Drug Induced: RHZE,NVP
  • 5. TUMORS
  • 6. Abscesses
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What Test do you want to carry out?

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  • -VITB12 folate, ferritin
  • Blood Cultures
  • PCR CMV
  • Lumbar puncture
  • Crag
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  • Urine MCS
  • Urine TB PCR
  • Repeat cx12
  • Sonar abdomen
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Are you Happy with the ARV regimen?

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  • No
  • Nephrotoxic
  • He has elevated Urea and

Creatinine What do you want to Change it to ??

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What do you want to change it to?

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Answer

Efavirenz

Abacavir/ Lamivudine (Kivexa)

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Would you Consider PCP as a cause of Tachypnoea?

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Answer

  • Yes
  • So he received high dose co-

trimoxazole

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Repeat Chest X-ray-7 days later Interstitial lung Pattern is present What are the causes of Interstitial Lung Pattern in HIV Patients?

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1.

Tuberculosis

  • 2. PCP
  • 3. Lymphangitis Carcinomatosis
  • 4. Pulmonary Oedema
  • 5. CMV-Infection
  • 6. Cryptococcus
  • 7. Diffuse Interstitial Lymphocytosis-

Children

  • 8. Castleman’s disease
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How would you make a diagnosis of Disseminated Tuberculosis in this Patient??

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  • 1. Bone Marrow Biopsy and Aspirate
  • TB Culture
  • Histology of the Bone
  • granulomas
  • 2. Urine TB PCR
  • 3. Liver Biopsy
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Would you give Empiric PCP Treatment? What is the Dose of Cotrimoxazole for PCP?

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Answer

15-30mg/Kg/Day of TMX P.O/ IV divided 6-8 hourly This Patients need 975mg TMX/3900 SMX Total Dose 4.875G / 24hours Each 15mls = 480G ≈ 150mls/24 hours

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What is the size effects of this High dose?

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  • 1. Bone Marrow Suppression on Aplastic

anemia, Agranulocytosis, Thrombocytopenic Purpura

  • 2. Drug Induced Liver Disease
  • 3. Cutaneous Hypersensitivity reaction-

sterens Johnson Syndrome TEN

  • 4. Cardiovascular : QT Prolongation

Leading to Ventricular Tachycardia and Torsades de Pointes

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The Patient Developed Bone Marrow

Suppression, He had severe Anemia and low platelets with epistaxis

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The platelet was low 31 x 109/L White Cell count was 2.7 HB dropped from 10 post transfusion to 7g/dl

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How would you manage this Complication?

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Rx Leucovorin Doses very according to severity and response Tablets are 15mg in Namibia He received 15mg 6 Hourly P.O

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The Urine TB PCR was Positive He was sensitive to Rifampicin

What is the Treatment of Choice?

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  • He developed Drug Induced Hepatitis

to RHZE

  • His eye became yellow 2 weeks after

starting RHZE

  • He had Tender enlarged Liver
  • He was Nauseous
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RHZE INDUCED LIVER DISEASE

Bilirubin had been normal and now it was 83.2 ALP Phosphatase rose to 629 IU/L.

  • The GGT rose to 1641 IU/L
  • Liver Biopsy confirmed Inflammation

and necrosis in the portal tracts but no granulomas

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What is the New Treatment

  • ption?
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Answer

Levofloxacin Streptomycin Ethambutol

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Could His have been due to Abacavir?

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Answer

  • NO
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He was Tested for the Genotype HLAB5701 which is associated with Abacavir Hypersensitivity and it was negative

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What about Cryptoccosis? Was this infection Possible ?

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Answer

  • Yes, CRAG was negative
  • n the blood
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CMV Infection: was this Possible?

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Answer Yes, CMV PCR was elevated; he did well on IV Ganciclovir for 5 days

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Current Status

He has returned to work He is on his TB Treatment, Low Dose Cotrimoxazole and ARV

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THANK YOU