1 / 19

Case 9

Case 9. 40 year-old woman From East Africa In UK for 10 years Living in London Widowed with two children. Case 9: 2007. Presented to GP with: dysphagia weight loss Referred by GP with suspected upper GI cancer Had “straight to test” upper GI endoscopy. Case 9: 2007. Case 9: 2007.

airell
Download Presentation

Case 9

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Case 9 40 year-old woman From East Africa In UK for 10 years Living in London Widowed with two children

  2. Case 9: 2007 Presented to GP with: • dysphagia • weight loss Referred by GP with suspected upper GI cancer • Had “straight to test” upper GI endoscopy

  3. Case 9: 2007 Case 9: 2007 At endoscopy: • Large ulcer in oesophagus • Thought to be malignant • Biopsied for histology • Told she probably had cancer • Staging CT of chest and abdomen • EUS ordered • Planned to see in clinic with the result

  4. Case 9: 2007 Investigations: • Biopsies: Inflammation and ulceration • No evidence of malignancy • CT scan: generalised mediastinal, hilar, para-aortic and axillary lymphadenopathy • “ulcerating tumour in mid oesophagus, T2”

  5. Case 9: clinic review • Registered with GP in 1999 • Several consultations with respiratory symptoms – diagnosed as asthma • Episode of pyelonephritis in 2001 when admitted for iv antibiotics for 24 hours • Consulted GP with diarrhoea in 2004, settled with imodium • GP noted borderline lymphopenia in 2006 - not investigated

  6. Case 9: 2007 Further investigations: • HIV test positive • Routine blood tests showed thrombocytopenia and borderline lymphopenia • CD4 count 45 • Viral load 95,000 • Biopsies restained for CMV – negative • Repeat biopsies and brushings negative for malignancy and TB and other infections

  7. Case 9: 2007 Diagnosis and outcome: • Giant benign oesophageal aphthous ulceration • Still received CMV treatment as well as antiretrovirals • Symptoms settled with oral thalidomide

  8. Case 9: summary 1999 Registered with GP 1999-2001 Seen by GP and in Respiratory OPD with ‘asthma’ 2001 Episode of pyelonephritis when admitted for iv antibiotics for 24 hours 2004 Seen by GP for diarrhoea, settled with imodium 2006 Found by GP to have borderline lymphopenia 2007 Weight loss, dysphagia HIV diagnosed: CD4 45: VL 95,000

  9. Q: At which of her healthcare interactions could HIV testing have been performed? • When she registered with her GP? (1999) • When she was seen in Respiratory OPD for asthma? (1999-2001) • When she was admitted with pyelonephritis? (2001) • When she was seen with diarrhoea? (2004) • When she was found to have lymphopenia? (2006) • When she presented with dysphagia and weight loss? (2007) • When she attended for her endoscopy? (2007) • Should she have been referred to GUM to see a trained counsellor before HIV testing?

  10. Who can test?

  11. Who to test?

  12. Rates of HIV-infected persons accessing HIV care by area of residence, 2007 Source: Health Protection Agency, www.hpa.org.uk

  13. Who to test?

  14. Who to test? Who to test? (cont.)

  15. Who to test? 2008 Report on the global AIDS epidemic HIV prevalence (%) in adults (15–49) in Africa, 2007 Source: UNAIDS Global Report 2008, www.unaids.org

  16. At least 6 missed opportunities! If current guidelines used, HIV could have been diagnosed 8 years earlier 1999 Registered with GP 1999-2001 Seen by GP and in Respirology OPD with ‘asthma’ 2001 Episode of pyelonephritis when admitted for iv antibiotics for 24 hours 2004 Seen by GP for diarrhoea, settled with imodium 2006 Found by GP to have borderline lymphopenia 2007 Weight loss, dysphagia HIV diagnosed: CD4 45: VL 95,000

  17. Learning Points • Oesophageal cancer is uncommon in this age group and her age and ethnic origin should have prompted consideration of other causes of dysphagia such as oesophageal candida • “Straight to test” protocols designed to expedite the diagnosis of malignancy may delay diagnosis and result in unnecessary tests in patients with HIV infection • Knowledge of a patient’s HIV status prior to endoscopy is not relevant in terms of infection control since universal precautions are taken, but may affect the decision as to what samples are taken (for example culture of biopsies for TB) or what further tests are requested.

  18. 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 >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

  19. Also contains UK National Guidelines for HIV Testing 2008 from BASHH/BHIVA/BIS Available from: enquiries@medfash.bma.org.uk or 020 7383 6345

More Related