Case 2
• 50 year-old man from Hong Kong
• In UK for 35 years
• Living in South Coast town
• Married 25 years
1
Case 2: PMH
Mid June 2006
GP referral to Gastroenterology
with history of weight loss and
anaemia Hb 8.5
End June 2006 OGD: antral gastritis with multiple
erosions: biopsies taken: benign
Mid July 2006
colonoscopy: normal to caecum
with no mucosa abnormalities
Planned OPD
6 weeks (no record)
2
Case 2: Autumn 2007
GP referral to Hepatology with abnormal LFTs
• ALP 196, Bilirubin 21, ALT 100 Hb 11.9, low
white cell count
Seen by Hepatology
• No history of liver disease; no jaundice; no
medications; no drug use; no herbal medications
or Chinese tea; no alcohol.
• In view of ethnicity? Chronic Hepatitis B
3
Case 2: Autumn 2007
• HBsAg positive, HBeAg positive, HCV negative
• USS normal; declined liver biopsy
• Liver screen otherwise normal (no HIV test)
• Started lamivudine and adefovir
4
Case 2: June/July 2008
GP referral to Oral Surgery: seen end June 2008
•
•
•
•
•
5
Large healing ulcer left palate
Biopsied beginning July 2008
Seen with result mid July 2008
Diffuse large B-cell lymphoma
Referred to Oncology
Case 2: PMH (cont.)
From GP letter of June 2008:
• Seen for severe psoriasis in Sept 2003
• Seen for oral candida in May 2006
6
Case 2: August 2008
Seen by Oncology beginning August 2008
• HIV test – positive
• B-cell lymphoma:
– localised disease
– No “B” symptoms
• R-CHOP commenced as inpatient
7
Case 2: August 2008
• HIV: CD4 count 0 (0%) VL 167,505
Resistance test sent
Antiretrovirals started mid August 2008
Truvada; Etravirine; Raltegravir; T-20
2 week CD4 1 VL 9404
Resistance test shows drug resistance (M184V)
8
Case 2: summary
Sept 2003 psoriasis
May 2006 oral candida
June 2006 anaemia, weight loss
OGD: gastritis, colonoscopy: NAD
Nov 2007 abnormal LFTs; low WCC
chronic hepatitis B
July 2008 ulcer on palate: large B-cell lymphoma
Aug 2008 HIV diagnosed: CD4 0: VL 167,505
9
Q: At which of his healthcare interactions
could HIV testing have been performed?
1.
2.
3.
4.
5.
6.
10
When he saw his GP for psoriasis?
When he saw his GP for oral candida?
When he was seen in Gastroenterology for
anaemia/weight loss?
When he was found by Hepatology to have low
WCC/hepatitis B?
When he was seen in ENT for oral surgery?
Should he have been referred to GUM to see a trained
counsellor before HIV testing?
Who can test?
11
Who to test?
Who to test?
12
Who to test?
13
Who to test?
14
5 missed opportunities!
If current guidelines used, HIV could have been
diagnosed up to 5 years earlier
Sept 2003 psoriasis
May 2006 oral candida
June 2006 anaemia, weight loss
OGD: gastritis, colonoscopy: NAD
Nov 2007 abnormal LFTs; low WCC
chronic hepatitis B
July 2008 ulcer on palate: large B-cell lymphoma
Aug 2008 HIV diagnosed: CD4 0: VL 167,505
15
Learning Points
• Because of his nadir CD4 of 0 he has an increased risk
of potential problems despite control of his HIV now
• He did not disclose any risk factors when his initial
medical history was taken
• 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
• Test for HIV before treating for hepatitis B as resistance
to lamivudine can compromise future HIV treatment
options
16
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 routine HIV testing for
patients diagnosed with hepatitis B and lymphoma
• HIV screening should become a routine test performed
whenever there is a clinical indicator such as oral
candida or weight loss
• Some patients may not disclose that they have put
themselves at risk of HIV infection in the past
17
Also contains
UK National Guidelines for HIV
Testing 2008
from BASHH/BHIVA/BIS
Available from:
enquiries@medfash.bma.org.uk
or 020 7383 6345
18