Tackling HIV Testing Case 10

Report
Case 10
63 year-old white UK male
Living in non-urban Eastern England
Married
Grown-up children
1
Case 10: March 2006
Referred by GP to ED
Seen by medical team and admitted with:
– Recurrent chest problems
– Cough
– SOB
2
Case 10: PMH
Seen by GP in Oct 2003 for itchy skin
problems and diarrhoea
• Investigations: FBC
–
–
–
–
–
lymphopenia (1.3)
anaemia (12.9)
low total WBC (3.7)
platelets 115
Total protein increased with globulins of 42
(diffuse hypergammaglobulinaemia)
Referred to Dermatology OPD
3
Case 10: PMH
Seen in Dermatology OPD
• Diagnosed with seborrhoeic dermatitis
• Treated with ketoconazole 2% cream
• In view of GI symptoms and haematological
abnormalities Dermatology suggested urgent GI
referral
Referred to Gastroenterology OPD
4
Case 10: PMH (cont.)
Seen in Gastroenterology OPD over 2004/05
• Numerous investigations
• Low folate and B12
• Treated with gluten-free diet but all tests for
coeliacs disease negative
• Diarrhoea and weight loss continue
• Upper endoscopy NAD
• Colonoscopy December 2005 NAD
5
Case 10: March 2006
Investigations:
• CXR fine widespread pulmonary infiltrates
• ? Vasculitis ? Lymphangitis carcinomatosis
Patient anxious, deteriorating, family worried
• Worsening SOB
Further investigations:
• CXR – showed deterioration from the admission X-ray
with diffuse interstitial shadowing both lung fields
• ? Pulmonary Embolism
• Angiogram done – no abnormality/evidence of PE seen
6
Case 10: April 2006
Radiologist doing angiogram queried
appearance of CXR
•? typical of PCP
GUM asked to see ‘just in case’
•Patient seen on ward – moribund
Transferred to ITU immediately
7
Case 10: ITU April 2006
• HIV test positive - CD4 = 40
• PCP, influenza, CMV pneumonia and
gastroenteritis, herpes simplex virus proctitis,
candidiasis and C.difficile
• Extremely unwell for some weeks
• Nearly died
• Eventually recovered and discharged
• Doing well on antiretroviral therapy (ART)
8
Case 10: summary
2003
Seen by GP for itchy skin problems and
diarrhoea, found to have lymphopenia
2003
Seen in Dermatology OPD for seborrhoeic
dermatitis
2004-2005 Seen in Gastroenterology OPD
with recurrent diarrhoea and weight loss
March 2006 Admitted with recurrent chest
infections, SOB
April 2006
PCP, CMV, HSV, oral candidiasis
HIV diagnosed: CD4 40
9
Q: At which of his healthcare interactions
could HIV testing have been performed?
1.
2.
3.
4.
5.
6.
10
When his GP detected lymphopenia?
When he was seen in Dermatology for seborrhoeic
dermatitis?
When he was seen in Gastroenterology OPD for recurrent
diarrhoea and weight loss?
When he was admitted with recurrent chest problems?
When he was investigated following abnormal CXR?
Should he have been referred to GUM to see a trained
counsellor before HIV testing?
Who can test?
Who can test?
11
Who to test?
12
Who to test?
13
At least 4 missed opportunities!
If current guidelines used, HIV diagnosed 2.5 years
earlier
2003
Seen by GP for itchy skin problems and
diarrhoea, found to have lymphopenia
2003
Seen in Dermatology OPD for
seborrhoeic dermatitis
2004-2005 Seen in Gastroenterology OPD
with recurrent diarrhoea and weight loss
March 2006 Admitted with recurrent chest infections, SOB
April 2006 PCP, CMV, HSV, oral candidiasis
HIV diagnosed (CD4 40)
14
Learning Points
• This patient had numerous investigations and a long ITU
stay, causing him and his family much distress and
costing the NHS thousands of pounds
• Because of his nadir CD4 of 40 he has an increased risk
of potential problems despite control of his HIV now
• He did not disclose any risk factors when his initial
medical history was taken
• 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
15
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 routine offer of an HIV test
for patients with lymphopenia
• HIV screening should become a routine test performed
whenever there is a clinical indicator such as chronic
diarrhoea or weight loss
• Some patients may not disclose that they have put
themselves at risk of HIV infection in the past
16
Also contains
UK National Guidelines for HIV
Testing 2008
from BASHH/BHIVA/BIS
Available from:
enquiries@medfash.bma.org.uk
or 020 7383 6345
17

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