Case 3

1. Case 3 • 67 year-old married woman • Born in West Africa • In UK for 27 years • Living in London • Visited her country of origin July – Sept 2007 • Husband died 2007 - cause unknown (rapid weight loss) • Son had died few months earlier – leukaemia

2. Case 3: April 2008 Presented to ED with 2-day history of: • Lethargy • Tiredness • Weight loss • Anorexia • Fevers • Night sweats

3. Case 3: PMH 1990 Ophthalmologist (routine) 1990 Registered with GP (HTN, DM, IBS, long- standing deranged LFTs) • 2006 Abnormal LFT • 2007 PUO, weight loss (? bereavement) 1996 Neurology (3 year history dizziness - BPV) 1999 Gynaecology - minor surgery 1998 – 2001 Gastroenterologist (IBS) • 2006 – 2007 Abnormal LFT 2008 Admitted elsewhere (Malaria) • Jan-April 2008 Post-malaria Px and ADR review • Since treatment fevers & headaches

4. Case 3: ward days 1 – 3 OE: • Well-looking • Lymphadenopathy • HR 83, BP 149/75, 97% O2, Temp 385 • Normal CVS, Respiratory, Neurological • Abdo – non-tender hepatomegaly • Nil else of note

5. Case 3: ward days 1 – 3 Initial investigations: • CXR clear • AXR NAD • Hb 8.1 (<->) WCC 12.9 Plt 120 • ESR 86 CRP 84 • ALP 399 (<->) Alb 22 (<->) Na 126 • Malaria films negative • USS abdo • GB sludge and 2-3 stones • Spleen slightly enlarged • Gastroscopy and biopsy • Candidal oesophagitis -> fluconazole • HIV Ab positive, CD4 ~200 (8%)

6. Case 3: ward days 4 – 5 • Transfused 3 units • Commenced co-trimoxazole • Empiric TB treatment considered but deferred • HIV positive with PUO +/- TB/lymphoma

7. Case 3: ward days 6 – 11 • Ongoing spiking temperatures 39+ • Deterioration • Drowsy • Disorientated • Septic Sputum and bloods AFB neg Further investigations: • CSF - no viral/bacterial/protozoal pathogens • CT head - no space-occupying lesion • CT abdo - generalized lymphadenopathy, splenomegaly – likely lymphoma • CXR - bilateral pleural effusions, RML shadow • Treatment: • Meropenem + teicoplanin • Co-trimoxazole increased to treatment dose • Frusemide • Fragmin

8. Case 3: ITU days 11- 20 Day 11 Admitted to ITU for respiratory support Day 12 Sudden deterioration - ARF, Intubated + ventilated - Inotropic support, Lip Amph B + Isoniazid + rifampicin Day 13 Multi-organ failure Day 20 Ongoing family involvement throughout - Treatment withdrawn - Died with family present Post-mortem: No precipitating cause found

9. Case 3: summary 1990 Ophthalmologist (routine) 1990 Registered with GP (HTN, DM, IBS, long- standing deranged LFTs) • 2006 Abnormal LFT • 2007 PUO, weight loss (? bereavement) 1996 Neurology (3 year history dizziness - BPV) 1999 Gynaecology - minor surgery 1998 – 2001 Gastroenterologist (IBS) • 2006 – 2007 Abnormal LFT 2008 Admitted elsewhere (Malaria) • Jan-April 2008 Post-malaria Px and ADR review • Since treatment fevers & headaches

10. Q: At which of her healthcare interactions could HIV testing have been undertaken? • When she registered with her GP? • When she was seen in Neurology for dizziness? • When she was seen in Gastroenterology for IBS? • When she was seen in Gynaecology for surgery? • When she was seen in Gastroenterology for deranged LFTs? • When she was seen by GP for PUO/weight loss? • When she was admitted for malaria? • Should she have been referred to GUM to see a trained counsellor before HIV testing?

11. Who can test?

12. Who to test?

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

14. Who to test?

15. Who to test?

16. 2008 Report on the global AIDS epidemic Who to test? HIV prevalence (%) in adults (15–49) in Africa, 2007 Source: UNAIDS Global Report 2008, www.unaids.org

17. At least 8 missed opportunities! If current guidelines used, HIV could have been diagnosed up to 18 years earlier 1990 Ophthalmologist (routine) 1990 Registered with GP (HTN, DM, IBS, long- standing deranged LFTs) • 2006 Abnormal LFT • 2007 PUO, weight loss (? bereavement) 1996 Neurology (3 year history dizziness - BPV) 1999 Gynaecology - minor surgery 1998 – 2001 Gastroenterologist (IBS) • 2006 – 2007 Abnormal LFT 2008 Admitted elsewhere (Malaria) • Jan-April 2008 Post-malaria Px and ADR review • Since treatment fevers & headaches

18. Learning Points • This patient came from an area of high HIV prevalence BUT had lived in the UK with a single partner for 27 years and so was perceived to be at low-risk of HIV • With no behavioural risk factors in the initial medical history, the otherwise excellent medical teams looking after her 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

19. 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 is>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

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