Transcript Case 11 General and Emergency Medicine

Case 11
• 71 year-old white male
• From the UK
• Had lived in London
• Retried to South Coast town
• Ex-smoker
• EtOH - 8 units day wine/spirits
• Unmarried, lived alone
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Case 11: June 2006
Admitted via Ophthalmology with:
• Probable HIV-related peripheral neuropathy
• Probable Pneumocystis jirovecii pneumonia
• CMV retinitis
Sexual history:
– Friend – long-term male partner
– no UPAI 15 years
Initial investigations:
BAL: confirmed PCP
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CD4 7; VL 200,000
Case 11: PMH
2000 Seen in Haematology for persisting lymphopenia
2000 Admitted with weight loss, watery diarrhoea
2001 Admitted with cerebellar infarct
2001 Seen in Neurology OPD (3 in London, 1 elsewhere)
for peripheral neuropathy - unknown cause
2003 Admitted with weight loss, OGD: oesophaghitis
2004 Admitted with fractured right neck of femur
• lymphocytes 0.5 (1.3-3.5)
• multiple mouth ulcers
• candida on mouth swab
2005 “Recurrent LRTIs” throughout 2005
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Case 11: June 2006
Seen in Ophthalmology OPD:
• vitreous detachment in left eye
• 2/12 history of acute onset unilateral cloudy
vision
OE:
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retinal necrosis
features characteristic of CMV retinitis
SOB
Refractory to antibiotics from GP
Admitted to hospital
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Case 11: June 2006
Management:
• Left vitrectomy and intraocular foscarnet
• D/w Genitourinary Medicine team:
“What is the current treatment for non-HIV-related CMV retinitis?”
• GUM team:
“Could this be HIV-related?”
Investigations:
• Rapid strip HIV test reactive
• Confirmatory 4th generation HIV test positive
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Case 11: June 2006
Further management:
• CMV retinitis
– Intraocular foscarnet
– Initiated on Valgancyclovir 900mg po bd
• 21/7 →maintenance
• PCP
– treated empirically with Co-trimoxazole, dose 120mg/kg bd
• 21/7 →prophylaxis
• HIV-related neuropathy
– Prednisolone 60mg po od
– Antiretroviral therapy initiated
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Case 11: June 2006
1 day prior to planned discharge:
• Septicaemic shock
• Died despite:
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vigorous fluid resuscitation
broad spectrum antibiotic cover
ITU admission
ventilatory support
maximal inotropic support
• Blood cultures grew Klebsiella terrigena
• Cause of death
– 1a: gram negative sepsis
– 1b: multi organ failure
– 1c: immunosupression 2°HIV
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Case 11: summary
2000 Haematology OPD, persisting lymphopenia
2000 Gen. med. admission, watery diarrhoea, weight loss
2001
2001
2003
2004
General medical admission, cerebellar infarct
Neurology OPD, peripheral neuropathy - unknown cause
Gen. med. admission, weight loss - OGD: oesophagitis
Fracture NOF, low lymphocytes, oral candida
- recorded in ED notes “lives with male partner”
2005 General medical admission, LRTI – low lymphocytes
2006 Ophthalmology OPD “non-HIV related CMV retinitis”
2006 HIV diagnosed: PCP: CD4 7: VL 200,000
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Q: At which of his healthcare interactions
could HIV testing have been undertaken?
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When he was seen with persistent lymphopenia? (2000)
When he was admitted with watery diarrhoea? (2000)
When he was admitted with cerebellar infarct? (2001)
When he was seen for peripheral neuropathy? (2001)
When he was admitted with weight loss and
oesophagitis? (2003)
When he was admitted with a fracture and disclosed
living with male partner? (2004)
When he was admitted with recurrent LRTI? (2005)
When he was seen for “non-HIV-related CMV retinitis”?
(2006)
Who can test?
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Who to test?
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Rates of HIV-infected persons accessing
HIV care by area of residence, 2007
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Source: Health Protection Agency, www.hpa.org.uk
Who to test?
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Who to test?
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Who to test?
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8 missed opportunities – 5 in ED - to diagnose HIV before
terminal presentation! If current guidelines used, HIV could have
been diagnosed 6 years earlier
2000 Haematology OPD, persisting lymphopenia
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2001
2001
2003
Gen. med. admission, watery diarrhoea, weight loss
General medical admission, cerebellar infarct
Neurology OPD, peripheral neuropathy - unknown cause
Gen. med. admission, weight loss - OGD: oesophagitis
2004 Fracture NOF, low lymphocytes, oral candida
- recorded in ED notes “lives with male partner”
2005 General medical admission, LRTI – low lymphocytes
2006 Ophthalmology OPD “non-HIV related CMV retinitis”
2006 HIV diagnosed: PCP: CD4 7: VL 200,000
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Learning Points
• This patient had numerous investigations and 5
admissions over 6 years, causing him much distress and
costing the NHS thousands of pounds
• Some patients might not disclose risk factors for HIV on
routine questioning in Outpatients even if the right
questions are asked
• Because of this the otherwise excellent medical teams
looking after him did not think of HIV even when the
diagnosis seems obvious with hindsight
• A perceived lack of risk should not deter you from
offering a test when clinically indicated
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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 universal HIV testing for
patients from groups at higher risk of HIV infection
• UK guidelines recommend screening for HIV in adult
populations where undiagnosed prevalence is >1/1000 as
it has been shown to be cost-effective
• HIV screening should become a routine test on
presentation of lymphopenia, PUO, chronic diarrhoea and
weight loss of otherwise unknown cause
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Also contains
UK National Guidelines for HIV
Testing 2008
from BASHH/BHIVA/BIS
Available from:
[email protected]
or 020 7383 6345
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