Case 9
40 year-old woman
From East Africa
In UK for 10 years
Living in London
Widowed with two children
1
Case 9: 2007
Presented to GP with:
• dysphagia
• weight loss
Referred by GP with suspected upper
GI cancer
• Had “straight to test” upper GI endoscopy
2
Case 9: 2007
At endoscopy:
Case 9: 2007
•
•
•
•
•
•
•
3
Large ulcer in oesophagus
Thought to be malignant
Biopsied for histology
Told she probably had cancer
Staging CT of chest and abdomen
EUS ordered
Planned to see in clinic with the result
Case 9: 2007
Investigations:
•
•
•
Biopsies: Inflammation and ulceration
No evidence of malignancy
CT scan: generalised mediastinal, hilar, paraaortic and axillary lymphadenopathy
•
“ulcerating tumour in mid oesophagus, T2”
4
Case 9: clinic review
• Registered with GP in 1999
• Several consultations with respiratory symptoms
– diagnosed as asthma
• Episode of pyelonephritis in 2001 when admitted
for iv antibiotics for 24 hours
• Consulted GP with diarrhoea in 2004, settled
with imodium
• GP noted borderline lymphopenia in 2006 - not
investigated
5
Case 9: 2007
Further investigations:
• HIV test positive
• Routine blood tests showed thrombocytopenia
and borderline lymphopenia
• CD4 count 45
• Viral load 95,000
• Biopsies restained for CMV – negative
• Repeat biopsies and brushings negative for
malignancy and TB and other infections
6
Case 9: 2007
Diagnosis and outcome:
• Giant benign oesophageal aphthous ulceration
• Still received CMV treatment as well as
antiretrovirals
• Symptoms settled with oral thalidomide
7
Case 9: summary
1999
1999-2001
2001
2004
2006
2007
8
Registered with GP
Seen by GP and in Respiratory OPD
with ‘asthma’
Episode of pyelonephritis when admitted for iv
antibiotics for 24 hours
Seen by GP for diarrhoea, settled with imodium
Found by GP to have borderline lymphopenia
Weight loss, dysphagia
HIV diagnosed: CD4 45: VL 95,000
Q: At which of her healthcare interactions
could HIV testing have been performed?
1.
2.
3.
4.
5.
6.
7.
8.
9
When she registered with her GP? (1999)
When she was seen in Respiratory OPD for asthma?
(1999-2001)
When she was admitted with pyelonephritis? (2001)
When she was seen with diarrhoea? (2004)
When she was found to have lymphopenia? (2006)
When she presented with dysphagia and weight loss?
(2007)
When she attended for her endoscopy? (2007)
Should she have been referred to GUM to see a trained
counsellor before HIV testing?
Who can 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
Who to test?
Who to test? (cont.)
14
Who to test?
2008 Report on the
global AIDS
epidemic
HIV prevalence (%) in adults (15–49) in Africa, 2007
Source: UNAIDS Global Report 2008, www.unaids.org
15
At least 6 missed opportunities!
If current guidelines used, HIV could have been
diagnosed 8 years earlier
1999
1999-2001
2001
2004
2006
2007
16
Registered with GP
Seen by GP and in Respirology OPD
with ‘asthma’
Episode of pyelonephritis when admitted for
iv antibiotics for 24 hours
Seen by GP for diarrhoea, settled with
imodium
Found by GP to have borderline lymphopenia
Weight loss, dysphagia
HIV diagnosed: CD4 45: VL 95,000
Learning Points
• Oesophageal cancer is uncommon in this age group and
her age and ethnic origin should have prompted
consideration of other causes of dysphagia such as
oesophageal candida
• “Straight to test” protocols designed to expedite the
diagnosis of malignancy may delay diagnosis and result
in unnecessary tests in patients with HIV infection
• Knowledge of a patient’s HIV status prior to endoscopy
is not relevant in terms of infection control since
universal precautions are taken, but may affect the
decision as to what samples are taken (for example
culture of biopsies for TB) or what further tests are
requested.
17
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 >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
18
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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