Case 3 Gastroenterology, Infectious Diseases

Report
Case 3
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67 year-old married woman
Born in West Africa
In UK for 27 years
Living in London
Visited her country of origin July – Sept 2007
Husband died 2007 - cause unknown (rapid
weight loss)
• Son had died few months earlier – leukaemia
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Case 3: April 2008
Presented to ED with 2-day history of:
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Lethargy
Tiredness
Weight loss
Anorexia
Fevers
Night sweats
Case 3: PMH
1990
1990
Ophthalmologist (routine)
Registered with GP (HTN, DM, IBS, longstanding deranged LFTs)
» 2006 Abnormal LFT
» 2007 PUO, weight loss (? bereavement)
1996
Neurology (3 year history dizziness - BPV)
1999
Gynaecology - minor surgery
1998 – 2001 Gastroenterologist (IBS)
» 2006 – 2007
Abnormal LFT
2008
Admitted elsewhere (Malaria)
» Jan-April 2008 Post-malaria Px and ADR
review
» Since treatment fevers & headaches
3
Case 3: ward days 1 – 3
OE:
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Well-looking
Lymphadenopathy
HR 83, BP 149/75, 97% O2, Temp 385
Normal CVS, Respiratory, Neurological
Abdo – non-tender hepatomegaly
Nil else of note
Case 3: ward days 1 – 3
Initial investigations:
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CXR clear
AXR NAD
Hb 8.1 (<->)
WCC 12.9
ESR 86
CRP 84
ALP 399 (<->)
Alb 22 (<->)
Malaria films negative
• USS abdo
– GB sludge and 2-3 stones
– Spleen slightly enlarged
• Gastroscopy and biopsy
– Candidal oesophagitis -> fluconazole
• HIV Ab positive, CD4 ~200 (8%)
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Plt 120
Na 126
Case 3: ward days 4 – 5
• Transfused 3 units
• Commenced co-trimoxazole
• Empiric TB treatment considered but deferred
• HIV positive with PUO +/- TB/lymphoma
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Case 3: ward days 6 – 11
• Ongoing spiking temperatures 39+
• Deterioration
– Drowsy
– Disorientated
– Septic Sputum and bloods AFB neg
Further investigations:
– CSF - no viral/bacterial/protozoal pathogens
– CT head - no space-occupying lesion
– CT abdo - generalized lymphadenopathy, splenomegaly – likely
lymphoma
– CXR - bilateral pleural effusions, RML shadow
– Treatment:
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Meropenem + teicoplanin
Co-trimoxazole increased to treatment dose
Frusemide
Fragmin
Case 3: ITU days 11- 20
Day 11
Day 12
Admitted to ITU for respiratory support
Sudden deterioration
- ARF, Intubated + ventilated
- Inotropic support, Lip Amph B + Isoniazid + rifampicin
Day 13
Day 20
Multi-organ failure
Ongoing family involvement throughout
- Treatment withdrawn
- Died with family present
Post-mortem: No precipitating cause found
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Case 3: summary
1990
1990
Ophthalmologist (routine)
Registered with GP (HTN, DM, IBS, longstanding deranged LFTs)
» 2006
» 2007
Abnormal LFT
PUO, weight loss (? bereavement)
1996
Neurology (3 year history dizziness - BPV)
1999
Gynaecology - minor surgery
1998 – 2001 Gastroenterologist (IBS)
» 2006 – 2007
2008
Abnormal LFT
Admitted elsewhere (Malaria)
» Jan-April 2008 Post-malaria Px and ADR
review
» Since treatment fevers & headaches
9
Q: At which of her healthcare interactions
could HIV testing have been undertaken?
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When she registered with her GP?
When she was seen in Neurology for dizziness?
When she was seen in Gastroenterology for IBS?
When she was seen in Gynaecology for surgery?
When she was seen in Gastroenterology for deranged LFTs?
When she was seen by GP for PUO/weight loss?
When she was admitted for malaria?
Should she have been referred to GUM to see a trained
counsellor before HIV testing?
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?
2008 Report on the
global AIDS epidemic
HIV prevalence (%) in adults (15–49) in Africa, 2007
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Source: UNAIDS Global Report 2008, www.unaids.org
At least 8 missed opportunities!
If current guidelines used, HIV could have been
diagnosed up to 18 years earlier
1990
1990
Ophthalmologist (routine)
Registered with GP (HTN, DM, IBS, longstanding deranged LFTs)
» 2006 Abnormal LFT
» 2007 PUO, weight loss (? bereavement)
1996
Neurology (3 year history dizziness - BPV)
1999
Gynaecology - minor surgery
1998 – 2001 Gastroenterologist (IBS)
» 2006 – 2007
2008
Abnormal LFT
Admitted elsewhere (Malaria)
» Jan-April 2008 Post-malaria Px and ADR review
» Since treatment fevers & headaches
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Learning Points
• This patient came from an area of high HIV prevalence
BUT had lived in the UK with a single partner for 27
years and so was perceived to be at low-risk of HIV
• With no behavioural risk factors in the initial medical
history, the otherwise excellent medical teams looking
after her 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
• 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
• HIV screening should become a routine test when
investigating PUO, chronic diarrhoea or weight loss of
otherwise unknown cause
• UK guidelines recommend universal HIV testing for
patients from groups at higher risk of HIV infection
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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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