Case 6
58 year-old man from North America
Married
Recently moved to London
1
Case 6: late 2005
Registered with GP - new patient check:
• Lipids normal
• Random glucose normal
• FBC normal - incidental finding: low platelets
Referred to Haematology OPD
2
Case 6: late 2005
Seen in Haematology OPD (wife present)
Investigations:
•
•
•
•
•
3
Platelet count 65 x 109/l (150 - 400 x 109/l)
No other symptoms
Patient stated: “No risk factors for HIV”
HIV test not performed
Bone marrow aspirate and trephine
(megakaryocytes present consistent with peripheral
destruction/consumption)
Case 6: late 2005
Diagnosis:
• ‘Auto-immune thrombocytopenia’
Plan:
• Observe
• GP to monitor platelet count
• No plan for active treatment
4
Case 6: late 2006
Patient re-referred by GP to Haematology
• Platelet count 56 x 109/l (150 - 400 x 109/l)
• Weight loss
Reviewed by Gastroenterologist/Urologist
• OGD, Colonoscopy, Cystoscopy performed: NAD
• Patient stated: “No risk factors for HIV”
5
Case 6: late 2006
• HIV test (after counselling): positive
• Patient recalls being bisexual in 1980s/1990s
and since
• Referral to HIV team
– CD4 146 (5%)
– VL 94,000
– No opportunistic infection
• Antiretroviral therapy commenced
6
Case 6: summary
2005
2005
2006
2006
Registered with GP, referral, low platelets
Seen in Haematology, thrombocytopenia
Re-referred to Haematology, low platelets
Seen by Gastroenterology and Urology
for weight loss
2006 HIV diagnosed: CD4 146: VL 94,000
7
Q: At which of his healthcare interactions
could HIV testing have been performed?
1.
2.
3.
4.
8
When he registered with his GP and was referred to
Haematology?
When he was first seen in Haematology?
When he was seen by Gastroenterology and Urology
for weight loss?
Only after being referred to GUM for counselling
before HIV testing?
Who can test?
9
Who to test?
10
Who to test?
11
Rates of HIV-infected persons accessing
HIV care by area of residence, 2007
12
Source: Health Protection Agency, www.hpa.org.uk
Who to test?
13
4 missed opportunities!
If current guidelines used, HIV could have been
diagnosed at least 13 months earlier
2005
2005
2006
2006
2006
14
Registered with GP, referral, low platelets
Seen in Haematology, thrombocytopenia
Re-referred to Haematology, low platelets
Seen by Gastroenterology and Urology
for weight loss
HIV diagnosed: CD4 146: VL 94,000
Haematological presentations
in HIV infection
Neutropenia
Anaemia
Thrombocytopenia
HIV
Lymphoma
15
Thrombocytopenia in HIV+
• Mode of presentation in ~ 10% (Sullivan et al,
1997)
• Thrombocytopenia in ~ 40% of patients
– Platelet count < 50 x 109/l in 1 - 5% cases
• Isolated thrombocytopenia
– does not affect overall prognosis (Holzman et al, 1987)
• May be managed differently from HIV negative
patients
16
Mechanisms underlying
thrombocytopenia
•
Reduced production
•
•
•
•
17
THINK HIV!
Immune
Disseminated intravascular coagulation (DIC)
Thrombotic thrombocytopenia purpura (TTP)
Abnormal distribution
•
•
Generalised bone marrow failure
Selective megakaryocyte defects
Increased consumption
•
•
•
THINK HIV!
Sequestration (splenomegaly: infection, haemophagocytosis, cirrhosis)
Dilutional
Classification of anaemias
Microcytic, hypochromic
Normocytic, normochromic
Macrocytic
MCV < 80 fl
MCV 80 – 95 fl
MCV > 95 fl
MCH < 27 pg
MCH > 27pg
Fe deficiency
Haemolytic anaemias
Megaloblastic
(immune, HUS, TTP, G6PD)
B12 + folate
Thalassaemia
Acute blood loss
Alcohol
Lead poisoning
Mixed deficiency
Liver disease
Sideroblastic anaemia
Parvovirus, Infection (MAI)
Myelodysplasia
Drugs (septrin, dapsone, GCV)
Drugs (AZT)
ANAEMIA OF CHRONIC DISEASE
HIV infection
18
Learning Points
• This man did not have an obvious risk factor when a
medical history was initially taken
• He had put himself at risk in the past but did not share this
with anyone on routine questioning in outpatients as his
wife was present
• Because of this the otherwise excellent medical teams
looking after him 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
• UK guidelines recommend routine opt-out HIV testing for
patients with thrombocytopenia
• 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
21