Transcript Tackling HIV Testing Case 7
Case 7
23 year-old woman From former Soviet state Arrived in UK October 2008 Living in London 1
Case 7: November 2008
2 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
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
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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 4
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 5
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 x10 9 /L • Treated empirically for bacterial pneumonia • → recovered • Patient DNAd follow-up appointment 6
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
b efore being seen in OPD… 7
Case 7: July 2009
Brought to ED of hospital 2 by her employer 8 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
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 9
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 10
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 11
Case 7: summary
Nov 2008 April 2009 June 2009 June 2009 July 2009 Admitted, PUO, severe bacterial pneumonia, (negative Hepatitis A, B and C serology) Admitted, recurrent bacterial pneumonia, weight loss Registered with GP Seen by GP with lethargy, anaemia and raised ESR Admitted, respiratory distress HIV diagnosed: severe PCP: CD4 100, VL 380,000 Inpatient 19 days
Includes 8 days on ICU
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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?
Who can test?
Who can test?
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Who to test?
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Who to test?
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Who to test?
HIV prevalence (%) in adults (15 –49) in Eastern Europe and Central Asia, 2007 2008 Report on the global AIDS epidemic
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Who to test?
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Rates of HIV-infected persons accessing HIV care by area of residence, 2007
19 Source: Health Protection Agency, www.hpa.org.uk
4 missed opportunities!
If current guidelines had been followed, HIV could have been diagnosed 9 months earlier
Nov 2008 April 2009 June 2009 June 2009 July 2009 Admitted, PUO, severe bacterial pneumonia, (negative Hepatitis A, B and C serology) Admitted, recurrent bacterial pneumonia, weight loss Registered with GP Seen by GP with lethargy, anaemia and raised ESR Admitted, respiratory distress HIV diagnosed: severe PCP: CD4 100, VL 380,000 Inpatient 19 days
Includes 8 days on ICU
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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 21
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 22
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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