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 • 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
Social History - Single - Employment – Available - Alcohol Consumption - High - Smoker
Examination Critically ill High Temperature 40 0 C High Respiratory rate 35/min Saturation 94% on 5L oxygen at weight 65.0 Kg Oedema +++ oral Candida Cheilosis
Examination Respiratory System Clear Clear Abdomen Distended Hepatomegaly CNS well oriented Clear Terminal neck Stiffness
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
LABORATORY RESULTS AVAILABLE GGT elevated 445 IU/L ALT elevated 87 IU /L AST elevated 241 IU /L LDH – 727
Chest Xray taken on 23/07/2017 Normal NORMAL
Question What is the cause of Fever ? What is the Cause of Anaemia? What is the Cause of Abnormal Liver Enzymes ?
Question What is the cause of Fever ? 1. Sepsis 2. IRIS 3. PCP, 4. TB 5. Lymphoma
Question What is the cause of Fever ?
Question What is the cause of Anemia ? 1. Blood Loss 2. Sepsis 3. Disseminated Infection – Bone marrow infiltration 4. Medication AZT
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
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
What Test do you want to carry out?
• -VITB 12 folate, ferritin • Blood Cultures • PCR CMV • Lumbar puncture • Crag
• Urine MCS • Urine TB PCR • Repeat cx12 • Sonar abdomen
Are you Happy with the ARV regimen?
-No - Nephrotoxic - He has elevated Urea and Creatinine What do you want to Change it to ??
What do you want to change it to?
Answer Efavirenz Abacavir/ Lamivudine (Kivexa)
Would you Consider PCP as a cause of Tachypnoea?
Answer - Yes - So he received high dose co- trimoxazole
Repeat Chest X-ray-7 days later Interstitial lung Pattern is present What are the causes of Interstitial Lung Pattern in HIV Patients?
Tuberculosis 1. 2. PCP 3. Lymphangitis Carcinomatosis 4. Pulmonary Oedema 5. CMV-Infection 6. Cryptococcus 7. Diffuse Interstitial Lymphocytosis- Children 8. Castleman’s disease
How would you make a diagnosis of Disseminated Tuberculosis in this Patient??
1. Bone Marrow Biopsy and Aspirate - TB Culture - Histology of the Bone - granulomas 2. Urine TB PCR 3. Liver Biopsy
Would you give Empiric PCP Treatment? What is the Dose of Cotrimoxazole for PCP?
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
What is the size effects of this High dose?
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
The Patient Developed Bone Marrow Suppression, He had severe Anemia and low platelets with epistaxis
The platelet was low 31 x 10 9 /L White Cell count was 2.7 HB dropped from 10 post transfusion to 7g/dl
How would you manage this Complication?
Rx Leucovorin Doses very according to severity and response Tablets are 15mg in Namibia He received 15mg 6 Hourly P.O
The Urine TB PCR was Positive He was sensitive to Rifampicin What is the Treatment of Choice?
-He developed Drug Induced Hepatitis to RHZE -His eye became yellow 2 weeks after starting RHZE -He had Tender enlarged Liver -He was Nauseous -
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
What is the New Treatment option?
Answer Levofloxacin Streptomycin Ethambutol
Could His have been due to Abacavir?
Answer - NO
He was Tested for the Genotype HLAB5701 which is associated with Abacavir Hypersensitivity and it was negative
What about Cryptoccosis? Was this infection Possible ?
Answer - Yes, CRAG was negative on the blood
CMV Infection: was this Possible?
Answer Yes, CMV PCR was elevated; he did well on IV Ganciclovir for 5 days
Current Status He has returned to work He is on his TB Treatment, Low Dose Cotrimoxazole and ARV
THANK YOU
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