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 1 Case 3: April 2008 Presented to ED with 2-day history of: • • • • • • 2 Lethargy Tiredness Weight loss Anorexia Fevers Night sweats Case 3: PMH 1990 1990 Ophthalmologist (routine) Registered with GP (HTN, DM, IBS, longstanding 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 3 Case 3: ward days 1 – 3 OE: • • • • • • 4 Well-looking Lymphadenopathy HR 83, BP 149/75, 97% O2, Temp 385 Normal CVS, Respiratory, Neurological Abdo – non-tender hepatomegaly Nil else of note Case 3: ward days 1 – 3 Initial investigations: – – – – – – CXR clear AXR NAD Hb 8.1 (<->) WCC 12.9 ESR 86 CRP 84 ALP 399 (<->) Alb 22 (<->) 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%) 5 Plt 120 Na 126 Case 3: ward days 4 – 5 • Transfused 3 units • Commenced co-trimoxazole • Empiric TB treatment considered but deferred • HIV positive with PUO +/- TB/lymphoma 6 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: • • • • 7 Meropenem + teicoplanin Co-trimoxazole increased to treatment dose Frusemide Fragmin Case 3: ITU days 11- 20 Day 11 Day 12 Admitted to ITU for respiratory support Sudden deterioration - ARF, Intubated + ventilated - Inotropic support, Lip Amph B + Isoniazid + rifampicin Day 13 Day 20 Multi-organ failure Ongoing family involvement throughout - Treatment withdrawn - Died with family present Post-mortem: No precipitating cause found 8 Case 3: summary 1990 1990 Ophthalmologist (routine) Registered with GP (HTN, DM, IBS, longstanding deranged LFTs) » 2006 » 2007 Abnormal LFT PUO, weight loss (? bereavement) 1996 Neurology (3 year history dizziness - BPV) 1999 Gynaecology - minor surgery 1998 – 2001 Gastroenterologist (IBS) » 2006 – 2007 2008 Abnormal LFT Admitted elsewhere (Malaria) » Jan-April 2008 Post-malaria Px and ADR review » Since treatment fevers & headaches 9 Q: At which of her healthcare interactions could HIV testing have been undertaken? 1. 2. 3. 4. 5. 6. 7. 8. 10 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? Who can test? 11 Who to test? 12 Rates of HIV-infected persons accessing HIV care by area of residence, 2007 13 Source: Health Protection Agency, www.hpa.org.uk Who to test? 14 Who to test? 15 Who to test? 2008 Report on the global AIDS epidemic HIV prevalence (%) in adults (15–49) in Africa, 2007 16 Source: UNAIDS Global Report 2008, www.unaids.org At least 8 missed opportunities! If current guidelines used, HIV could have been diagnosed up to 18 years earlier 1990 1990 Ophthalmologist (routine) Registered with GP (HTN, DM, IBS, longstanding 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 2008 Abnormal LFT Admitted elsewhere (Malaria) » Jan-April 2008 Post-malaria Px and ADR review » Since treatment fevers & headaches 17 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 18 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 19 Also contains UK National Guidelines for HIV Testing 2008 from BASHH/BHIVA/BIS Available from: enquiries@medfash.bma.org.uk or 020 7383 6345 20