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Case 11

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. Case 11: June 2006. Admitted via Ophthalmology with: Probable HIV-related peripheral neuropathy

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Case 11

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  1. 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

  2. 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 CD4 7; VL 200,000

  3. 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

  4. Case 11: June 2006 Seen in Ophthalmology OPD: • vitreous detachment in left eye • 2/12 history of acute onset unilateral cloudy vision OE: • retinal necrosis • features characteristic of CMV retinitis • SOB • Refractory to antibiotics from GP Admitted to hospital

  5. 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

  6. 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

  7. Case 11: June 2006 1 day prior to planned discharge: • Septicaemic shock • Died despite: • 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

  8. Case 11: summary 2000 Haematology OPD, persisting lymphopenia 2000 Gen. med. admission, watery diarrhoea, weight loss 2001 General medical admission, cerebellar infarct 2001 Neurology OPD, peripheral neuropathy - unknown cause 2003 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

  9. Q: At which of his healthcare interactions could HIV testing have been undertaken? • 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)

  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?

  15. Who to test?

  16. 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 2000 Gen. med. admission, watery diarrhoea, weight loss 2001 General medical admission, cerebellar infarct 2001 Neurology OPD, peripheral neuropathy - unknown cause 2003 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

  17. 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

  18. 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

  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

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