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VIRTUAL MEDZONE

VIRTUAL MEDZONE. Your Resource for HIV Related Innovative Medical Communication. CASE PRESENTATIONS. Mahin Baqi MD FRCPC Ken Logue MD David Fletcher MD FRCPC. CASE 1. 58 y.o . man HIV + 1989 CD4 200 on diagnosis Previous history of depression and chronic intermittent diarrhea.

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VIRTUAL MEDZONE

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  1. VIRTUAL MEDZONE Your Resource for HIV Related Innovative Medical Communication

  2. CASE PRESENTATIONS MahinBaqi MD FRCPC Ken Logue MD David Fletcher MD FRCPC

  3. CASE 1 • 58 y.o. man • HIV + 1989 • CD4 200 on diagnosis • Previous history of depression and chronic intermittent diarrhea

  4. CASE 1

  5. CASE 1 • 2001 stopped meds due to neuropathy, ongoing viremia and chronic diarrhea • CD4 104 HIV VL 266, 131 c/ml • No genotype available

  6. CASE 1 • Restarted AZT/3TC/Abacavir/Lopinavir/ Amprenavir/Nevirapine

  7. CASE 1 GENOTYPE SEPTEMBER2001

  8. CASE 1

  9. CASE 1 • AZT/3TC/Abacavir/Lopinavir/Amprenavir/Nevirapine/Fenofibrate/Fish oil/Niacin

  10. CASE 1 AZT/3TC/Abacavir/Lopinavir/Amprenavir/Nevirapine/Fenofibrate/Fish oil/Niacin • 104 wks… CD4 150 VL 14,895 c/ml • Went to Kingston, Ontario in 2003 to live with partner

  11. CASE 1 • Returned to Toronto in 2005 on D4T/Tenofovir/ddI/Fuzeon • CD4 100 VL 18,295 c/ml

  12. CASE 1 GENOTYPE June 2005

  13. CASE 1 Genotype September 2005

  14. CASE 1 WHAT WOULD YOU DO?

  15. CASE 1 • Tropism Testing…R5 2005-2007 3TC/Maraviroc/Lopinavir/Amprenavir /T20 • CD4 165-250 VL 4,000-10,000

  16. CASE 1 Genotype January 2007

  17. CASE 1 2007 • anal carcinoma in situ • Lipids terrible…Triglycerides >40mmole/l develops pancreatitis, bowel obstruction • ARVS discontinued

  18. CASE 1 Late 2007 3TC/T20/Ritonavir/Darunavir/Etravirine/ Raltegravir/Maraviroc • CD4 30 on initiation

  19. CASE 1

  20. CASE 1 2008 • Develops Diabetes on regimen – Metformin initiated • Triglycerides continue out of control despite bezafibrate/fish oil/crestor • Angina → Severe CAD → CABG

  21. CASE 1 2008 • T20 stopped due to injection site reactions and associated fatigue…viral load remains <50 on 3TC/Ritonavir/Darunavir/ Etravirine/ Raltegravir /Maraviroc

  22. CASE 1 • Lipids remain terrible with TG>40mmole/l • Bezafibrate/fish oil/Ezetrol/Crestor/ ASA/Coumadin • Recurrent angina – 4/5 bypassed vessel restenosed via angiography WHAT WOULD YOU DO?

  23. CASE 1 Late 2008 • Ritonavir/Darunavir discontinued • Remains on 3TC/Maraviroc/Raltegravir /Etravirine • CD4 275 VL <50! • TG 34.70→ 3.78 – 6.07

  24. CASE 1 2009/10 3TC/Maraviroc/Raltegravir/Etravirine • Angina free, mitral regurgitation, Grade 1 LV • CD4 250-275 VL <50! • TG 8.46-6.07 • LDL <0.5 • HDL 0.5-0.6

  25. CASE 1 2010 • Furosemide/Perindopril for mitral regurgitation • Some intermittent orthopnea • Stable angina • New onset prostatism

  26. CASE 1 What would you do ?

  27. CASE 1 • No NSAIDS • No New Meds/holistics/illicit drugs • Not dry on clinical examination • Normotensive • No CHF clinically • No swelling of ankles

  28. CASE 1 • U/S – no obstruction • U/A – normal albumin/creatinine + protein/creatinine ratio • Urinalysis normal • Urine sodium-100 mmol/l CAUSE? MANAGEMENT?

  29. CASE 1 Perindopril + Furosemide discontinued EGFR 45-50 ml/min

  30. CASE 1 Given sudden onset, bland urinalysis and lack of significant proteinuria, likely cause is vascular …awaiting MRI Angiography of kidneys

  31. CASE 1 Doses of all medications readjusted for renal dysfunction Not required for 3TC/Maraviroc/Raltegravir/ Etravirine

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