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CASE 1

CASE 1. 54 yo man HIV+ 2005 Generalized Anxiety/OCD VL 15,185 CD4 ranges from 340 - 390 Baseline Genotype clear. CASE 1. Severe intermittent diarrhea – Giardiasis, new psychiatric meds Increasing anxiety/OCD 2005-07 CD4 300 - 390 VL 10,000 – 15,000. CASE 1. Mid-late 2007

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CASE 1

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  1. CASE 1 • 54 yo man HIV+ 2005 • Generalized Anxiety/OCD • VL 15,185 • CD4 ranges from 340-390 • Baseline Genotype clear

  2. CASE 1 • Severe intermittent diarrhea – Giardiasis, new psychiatric meds • Increasing anxiety/OCD • 2005-07 • CD4 300 - 390 • VL 10,000 – 15,000

  3. CASE 1 • Mid-late 2007 • CD4… 280, 230, 170 • VL 35,000 – 50,000 • Fatigue/intermittent diarrhea • increasing anxiety/OCD • Feels like he is going to die from AIDS

  4. CASE 1 • Late 2007 • Initiates TDF+FTC/Nevirapine • Week 1 • Abdo pain with normal liver enzymes • Day 14 • Fever/maculopapular rash/weakness/flu-like illness • ARV’s discontinued

  5. CASE 1 • 2007-09 • TDF+FTC/Delaviridine as patient concerned about PI related fat changes/potential Efavirenz related anxiety/depression • CD4 200→490 • VL <50x5, 133, 117, 189

  6. CASE 1 • 2007-09 TDF+FTC/Delaviridine • Increasingly incapacitating fatigue • Crestor, Zoloft, Clonazepam, Neurontin…discontinued with no improvement in fatigue

  7. CASE 1 • 2009 • TDF+FTC/Delaviridine • CD4 250 • VL 2521 • Adherence was suspect and ARVS discontinued • No dramatic improvement in fatigue for the record

  8. CASE 1 GENOTYPE JUN/09

  9. CASE 1 • What would you do?

  10. CASE 1 • TDF+FTC/RTV/Darunavir/Etravirine • CD4 250→350 • VL 98,636…486 (month 1),232 (month 2), 94 (month 3), 73 (month4), 60 (month 5) 58 • What would you do?

  11. CASE 1 • TDF+FTC/RTV/Darunavir/Etravirine continued • CD4 380 • VL <50x3 (last 8/10)

  12. CASE 1…another issue • January 2010 • 6 months post-initiation of TDF/FTC/RTV/Darunavir/Etravirine liver enzymes begin to rise • Serology revealed HEP A & B immune

  13. CASE 1 • No New Meds/No illicit drugs

  14. CASE 1 • Cause? • What would you do?

  15. CASE 1 • Urinary Drug Screen done • Methamphetamine detected • Patient was brought in and the above findings discussed including the concept of a methamphetamine induced hepatitis…importance of abstinence outlined

  16. CASE 1 • Do you stop ARVs?

  17. CASE 1 • Surprise!...FEB/10…Hep C AB neg • HCV RNA 3.35 x107 • Genotype 3 • ARVs continued with weekly monitoring

  18. CASE 1 • Do you stop ARVs?

  19. CASE 1 • ALT began to decline after peaking at 1268 despite continuing ARVs • It was felt that CD4 maintenance and HIV viral load suppression was important for hepatitis C self-cure…also no evidence of pre-existing liver disease

  20. CASE 1 • Probable Hepatitis C self-cure

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