Case 7
23 year-old woman
From former Soviet state
Arrived in UK October 2008
Living in London
1
Case 7: November 2008
Presented to ED of hospital 1
4-day history of:
• Fever
• Sweats
• Dry cough
2-day history of:
• Pleuritic right-sided chest pain
• Rigors
• Shortness of breath
2
Case 7: November 2008
On admission to hospital 1:
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Unwell
Right pleural rub
Bronchial breathing at Right base
PaO2 = 9.5 kPa (on air)
CXR = Right lower lobe pneumonia
Blood cultures confirmed Strep. pneumoniae
Case 7: November 2008
• Given benzylpenicillin/clarithromycin →
recovered
• Persistently elevated ALT (=71, Normal<50)
• USS normal
• Hepatitis A, B, and C serology negative
• Seen for follow up in OPD, 2 weeks after
• Hospital discharge.
• LFTs now normal
• Was well → no further follow-up
4
Case 7: April 2009
Re-presents to ED of hospital 1
3-day history of:
• Cough with rusty sputum
• Fever with sweats
• Chills
• Headache
• Reported 8kg weight loss over previous 5
months
5
Case 7: April 2009
OE:
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Signs of Left upper lobe consolidation
CXR = L upper lobe pneumonia
Sputum/blood culture = negative
Peripheral blood WBC = 12.3 x109/L
Treated empirically for bacterial pneumonia
→ recovered
Patient DNAd follow-up appointment
Case 7: June 2009
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Moved to new job
Now registered with GP
Visits GP - reports she is unwell, lethargic
GP finds nil abnormal on examination
Blood tests: Monospot negative,Hb 9.9 g/dl, MCV
normal, ESR 50 mm/hr
• Referred by GP to Haematology OPD of hospital 2
BUT before being seen in OPD…
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Case 7: July 2009
Brought to ED of hospital 2 by her employer
OE:
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Severely unwell
Cyanosed
Tachypnoeic (resp rate = 26/min)
Pyrexial, T = 38.4 degC
Also - ED ST2 notices oral candida and oral
hairy leukoplakia on tongue
Case 7: July 2009
Investigations:
• PaO2 (on air) = 6.9 kPa
• CXR = marked bilateral infiltrates
• ST2 queries underlying HIV infection
- begins empirical therapy for PCP
• Patient transferred from ED to ICU
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Case 7: July 2009
On ICU:
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With supplemental oxygen (FiO2 = 60%) →
Better oxygenated
ICU Consultant offers patient an HIV test
Offer accepted
HIV test is positive
CD4 count = 100 cells/µl
Viral load = 380 000 copies/ml
Case 7: July 2009
• PCP treatment continued
(high-dose co-trimoxazole and methyprednisolone) →
improvement in oxygenation
• On day 4 of ICU admission patient deteriorates, with
worsening oxygenation following fibreoptic bronchoscopy
and BAL (confirms PCP)
• CXR excludes pneumothorax
• CPAP given for 3 days→ patient improves
• Discharged to general ward after 8 days on ICU
• Began ARVs after 14 days of PCP therapy → continued
improvement
• Discharged from hospital on day 19
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Case 7: summary
Nov 2008
April 2009
June 2009
June 2009
July 2009
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Admitted, PUO, severe bacterial pneumonia,
(negative Hepatitis A, B and C serology)
Admitted, recurrent bacterial
pneumonia, weight loss
Registered with GP
Seen by GP with lethargy, anaemia and
raised ESR
Admitted, respiratory distress
HIV diagnosed: severe PCP: CD4 100, VL 380,000
Inpatient 19 days
Includes 8 days on ICU
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2.
3.
4.
5.
6.
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Q: At which of her healthcare
interactions could/should HIV
testing
been
When
she firsthave
presented
withperformed?
severe bacterial
pneumonia?
When tests for viral hepatitis were performed?
When she re-presented with bacterial pneumonia and
weight loss?
When she registered with a GP?
When she presented to GP with lethargy and was
found to have anaemia and a raised ESR?
Should she have been referred to GUM to see a
trained counsellor before HIV testing?
Who can test?
Who can test?
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Who to test?
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Who to test?
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Who to test?
2008 Report on the
global AIDS epidemic
HIV prevalence (%) in adults (15–49)
in Eastern Europe and Central Asia, 2007
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Who to test?
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Rates of HIV-infected persons accessing
HIV care by area of residence, 2007
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Source: Health Protection Agency, www.hpa.org.uk
4 missed opportunities!
If current guidelines had been followed, HIV could
have been diagnosed 9 months earlier
Nov 2008
April 2009
June 2009
June 2009
July 2009
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Admitted, PUO, severe bacterial pneumonia,
(negative Hepatitis A, B and C serology)
Admitted, recurrent bacterial pneumonia,
weight loss
Registered with GP
Seen by GP with lethargy, anaemia and
raised ESR
Admitted, respiratory distress
HIV diagnosed: severe PCP: CD4 100, VL 380,000
Inpatient 19 days
Includes 8 days on ICU
Learning Points
• This patient came from an area of high HIV prevalence,
but was not offered an HIV test in several contacts with
healthcare services
• This patient had numerous investigations including 3
admissions and an ITU stay, causing her much distress
and costing the NHS thousands of pounds
• Because of her nadir CD4 of 100 she has an increased
risk of potential problems despite control of her HIV now
• A perceived lack of risk should not deter you from
offering a test when clinically indicated
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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 screening for HIV in adult
populations where undiagnosed prevalence is >1/1000 as
it has been shown to be cost-effective
• UK guidelines recommend universal HIV testing for
patients from groups at higher risk of HIV infection
• HIV screening should be a routine test on presentation of
bacterial pneumonia, and PUO, anaemia or weight loss of
otherwise unknown cause
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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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