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CASE 1

CASE 1. 55 yo man HIV+ since 1986 CD4 nadir 240 in 1990. CASE 1. 2009 Presyncope / syncopal episodes EKG LBBB Stress Echo – normal Holter – episodes of rapid ventricular tachycardia. CASE 1. 2009 Presyncopal / syncopal episodes EPS Study

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CASE 1

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  1. CASE 1 • 55 yo man • HIV+ since 1986 • CD4 nadir 240 in 1990

  2. CASE 1 2009 Presyncope/syncopal episodes • EKG LBBB • Stress Echo – normal • Holter – episodes of rapid ventricular tachycardia

  3. CASE 1 2009 Presyncopal/syncopal episodes • EPS Study • Inducible rapid VT, but non re-entrant (no RF ablation) • Implanted defibrillator

  4. CASE 1 2012 • Long–standing history of frequent loose BMs presumed to be due to the Protease component (required) of his ARV regimen (Saquinavir, Atazanavir, RTV/Lopinavir in past)

  5. CASE 1 2013 Abacavir/3TC/RTV/Darunavir/Nevirapine • CD4 500 • Viral load <40 • 10 BMS/day – worsened over past year

  6. CASE 1 FEB 2013 • Seen by gastroenterology • Colonoscopy was grossly normal and colonic biopsies revealed microscopic colitis compatible with “Collagenous Colitis” • A 3 month course of high dose oral Budesonide was prescribed

  7. CASE 1 MAR 2013 • Diarrhea dramatically improved despite continuing ARV regimen (ABC/3TC/RTV/ DRV/NVP) • Becoming Cushingoid/hypertensive • Budesonide dose dropped by 2/3

  8. CASE 1 APR 2013 – 2 wks later • Diarrhea still improved • Normotensive/still Cushingoid • ACTH <2 pmole/l • Cortisol <11 nmol/l

  9. CASE 1 APR 2013 – 2 wks later • Appearance of MULTIPLE CUTANEOUS KS LESIONS!!!!

  10. CASE 1 APR 2013 • Rapid taper of Budesonide • Increasing cutaneous KS lesions (>25) • Re-appearance of loose BMS

  11. CASE 1 MAY-AUG 2013 • Increased BMs • Rapid flattening + fading of pre-existing KS lesions • No new KS lesions • Re-addressing ARVs and their contribution to diarrhea

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