Keri Giron
Nutrition 528
Case Study 35:
AIDS with Opportunistic Infections
1. How is HIV transmitted? After reading Mr. Long’s history and
physical, what risk factors would you say he has had for contracting
HIV?
HIV can be transmitted through sexual contact (semen, vaginal, and
cervical secretions), through blood contact (IV drug use, contaminated
needles, and transfusions prior to 1985), and perinatally (breast milk).
Mr. Long did have a blood transfusion, but it does not indicate in what
year. He is also a recreational user of drugs, so it could also be IV drug
use with a contaminated needle.
2. Mr. Long says he found out he was HIV positive four years ago.
Why is he only symptomatic now?
Many times, the virus is dormant for years before being symptomatic. It
can be asympotmatic up to ten years or more.
3. The history and physical indicate that he is seropositive. What does
that mean? The Western Blot and ELISA confirmed that he was
seropositive. Describe these tests.
Seropositive indicates that the patient is HIV positive and the virus is
detected in the serum of the blood. The ELISA test detects antibodies
produced in response to HIV infection and is used as a primary test for
HIV. The secondary test for HIV is the Western Blot assay. This test
allows identification of antibodies to specific viral antigens. It is usually
done if a false-positive ELISA test result occurs and identifies if the
patient is or is not infected with HIV. The Western Blot assay is much
more specific than the ELISA.
4. What is thrush, and why might Mr. Long has this condition?
Oral thrush is an infection of yeast fungus, Candida albicans, in the
mucous membranes of the mouth and throat. It can cause painful white
plaques on the lining of the oral cavity and on the tongue. Candida
exists in half of the population, but it does not become a problem until
there is a change in the chemistry of the oral cavity that favors
candida over the other microorganisms that are present. These
changes can occur as a side effect of taking antibiotics or drug
therapy, like chemotherapy. It also can be caused by certain conditions
as a consequence of AIDS.
5. What are common nutritional complications of HIV and AIDS? After
reading Mr. Long’s history and physical, can you identify any of these
complications in him?
Malnutrition is one of the most important complication of HIV and AIDS.
Whether it is malabsorbtion, or not enough oral intake, patients with HIV
and AIDS are malnourished. This malnourishment leads to weight loss
and wasting. Another complication in patients with HIV or AIDS is oral
thrush. This can cause a loss of appetite, white plaques within the oral
cavity, mouth discomfort, and a change in taste. This complicates eating
any type of food that is hard, spicy, or gritty. Diarrhea is another
common nutritional complication of HIV and AIDS. It leads to
malabsorption of many important nutrients the body needs to rebuild
tissues and cells. Kaposi’s sarcoma is a common disease of patients and
can cause lesions in the oral cavity or esophagus leading to difficulty
chewing and swallowing causing pain. Kaposi’s sarcoma lesions can also be
found in the intestinal tract and may cause obstructions within the
intestines. Mr. Long has oral thrush and possibly Kaposi’s sarcoma.
6. After this admission Mr. Long was diagnosed with AIDS, Category
C2. What information can you see from his medical record that
confirms this diagnosis?
Esophageal candidiasis is one of the many symptoms of a patient within
Category C. For category 2, the CD4+ T-cell count is inbetween 200 and
499 cells/L.
7. Evaluate the patient’s anthropometric information.
Calculate % UBW and BMI.
%UBW= 162.5/ 184(100)= 88% - little underweight
BMI= 162.5 lbs./ (73 inches) squared (705)= 21.5, so 22- acceptable
weight
8. Compare the TSF to population standards. What does this
comparison mean? Is this a viable comparison? Explain.
Mr. Long has a TSF of seven millimeters. For his race and age, the
mean measurement is 11.8 millimeters, making him well below the
mean. He is within the 25th and 50th percentile of his age class.
This is not a viable comparison because there are only 119 people that
were tested in his age range. He may be much lower in percentile if
more people were added to the study. He might also be higher in the
percentile, however, he is below the mean indicating a problem with
weight loss.
Using MAC and TSF, calculate upper arm muscle area. What can you
infer from this calculation?
100 cm - 54cm= 46 cm
Mr. Long’s upper arm muscle area is smaller than the upper arm area
with skin and fat. His muscles are either not very big, or are
atrophying down.
Mr. Long’s body fat percentage is 12.5%. What does this mean?
Compare to standards.
He is right on the borderline for low body fat percentage. The
standards for men are 12-20% for a healthy percentage of fat. Mr.
Long is right on the cusp of this breakdown.
Summarize Mr. Long’s nutritional risk (if any from your assessment of
anthropometric information.
Mr. Long’s weight is a little concerning, since he is only 88% of his
IBW. I am also concerned with the muscle area in his arm. I might
have done the wrong calculations, however if the answer is correct,
Mr. Long’s muscles are weakened and being broken down. This is a
great nutritional risk. Mr. Long’s fat percentage of 12.5% is
something that should be monitored to keep stable at 12.5 or higher.
If it should fall anymore, a nutritional mishap could occur.
9. Evaluate Mr. Long’s dietary information. What tools could you use
to evaluate his dietary intake? Does he seem to be consuming
adequate amounts of food? Can you identify anything from his
history that indicates he is having difficulty eating? Explain.
I would use a nutrient intake analysis to evaluate the dietary intake of
Mr. Long. Since he is barely eating, he will probably be deficient in many
nutrients. To help with this nutrient analysis, I would also add one of the
following to better understand the types of foods Mr. Long eats on a
regular basis: 24-hour recall, food diary, and/or general food frequency
questionnaire. I do not think Mr. Long is consuming adequate amounts of
food. The foods he does consume are all soft indicating that he is having
difficulty eating rough, harder to chew foods. He also states, “I thought
if I wasn’t eating like I should that I could at least take supplements.”
10. Mr. Long states that he consumes alcohol several times a week.
Are there any contraindications for alcohol consumption for him?
Yes! There are many reasons Mr. Long should not be drinking alcohol.
For starters, the liver is trying hard to break down all of those
supplements that Mr. Long is taking and it cannot function to its full
capacity with alcohol in its way. The liver will detoxify the alcohol first
(slowly), creating the medications and supplements to not be as effective
as they were without the alcohol in the system. He may also have drug
interactions inbetween the medications and the alcohol. This can cause
many unwanted side effects. The alcohol also puts a hold on any of the
functions of the liver dealing with the immune system. The alcohol is
overall non-nutritious and detrimental to anyone, especially to those with
HIV.
11. Using this patient’s laboratory values, identify those labs used to
monitor his HIV. What do these specifically measure, and how
would you interpret them for him?
Mr. Long has many labs that monitor his HIV. His mean corpuscular
hemoglobin (MCH) and mean corpuscular hemoglobin concentration (MCHC)
are high and measure the amount and volume of hemoglobin in the average
cell. The MCH results from dividing total hemoglobin by total RBCs. If the
count is high this indicates that the cells are larger than normal. AZT may
cause the MCV to rise above normal, which may also happen if there is a B12
deficiency.
Mr. Long's lymph and %lymphocytes were very low. Lymphocytes (lymphs)
are cells that produce antibodies, regulate the immune system, and fight
viruses and tumors. Mr. Long's monocytes or macrophages (monos) were
high and are the WBCs involved in fighting bacterial infections. Eosinophils
(Eos) are WBCs usually involved in allergic-type reactions. His eosinophils
are elevated slightly. An elevated eosinophil percentage can help in
diagnosing certain types of allergic diseases. Mr. Long's LDH level is
extremely high. LDH is commonly high in patients with HIV and AIDS
indicating that the patient has histoplasmosis, a fungal infection. This is why
Mr. Long is on oral Diflucan.
12. What laboratory values can be used to evaluate nutritional status?
Are there any for Mr. Long that identify nutritional risk?
Decreases with HIV/AIDS:
-Apo A and Apo B
-Total cholesterol
-HDL's and LDL's
-Hemoglobin
-WBC's
-Na
Increases with HIV/AIDS:
-CPK/CK
-TG's
-K with acute AIDS
13. Calculate Mr. Long’s optimal energy and protein intake. How does
this compare to his diet history?
BEE= 66+ [13.7 X 73] + [5 X 185.42] - [6.8 X 32]
BEE= 1775.6 kcals, so 1776 kcals
TEE= 1776 X 1.5= 2663.4, which I rounded to 2700 kcals a day
PRO= 1.5 (73kg) = 109.5= 110 g PRO a day
Mr. Long is definately not getting enought calories with nutrients that
he needs. He has a lot of empty calories within his diet.
14. What other information would you want to obtain from Mr. Long in
order to fully evaluate his nutritional status?
I would want to take a food day diary for at least a week if possible.
If not possible, at least a 24-hour recall that is more detailed. A
questionnaire of regularly eaten foods would be helpful as well. There
was no activity/exercise routine listed, so maybe look into that also.
15. Mr. Long was started on three medications that he will be
discharged on.
Identify these medications and the purpose of each.
1. AZT(zidovudine)- antiretroviral. Reduces viral concentrations
in the blood.
2. Crixivan (indinavir)- antiretroviral. Reduces viral
concentrations in the blood.
3. Epivir (lamivudine)- antiretroviral nucleoside analog. Reduces
viral concentrations in the blood.
4. Oral Diflucan- antifungal. Kills the fungus.
16. Are there specific drug-nutrient interactions to be concerned
about? Explain.
1.
Minor: headache, insomnia, nausea, GI upset, myalgia, malaise.
Major: neutropenia, anemia, occasional hepatotoxicity, peripheral
neuropathy, myositis
2. A few people may get hemolytic anemia if taking Crixivan. It may
cause flare up and liver damage and may cause kidney stones. Hair
loss, dry skin, and ingrown toenails are all side effects. It can also
cause HTN and diabetes.
3. N/V, headache, vommiting, and rare cases of hair loss. Nucleoside
analog anti-HIV drugs can cause lactic acidosis and severe
hepatomegaly leading to fatty liver.
4. Nausea, headache, rash, vomiting, abdominal pain, diarrhea, and
hepatotoxicity.
Is there specific information you would want Mr. Long to know
about taking these medications?
Mr. Long should make sure to get a liver function test, a serum
creatinine test, and a CBC to make sure everything is back to
normal. Mr. Long should also use the Epivir and the AZT in
combination, or the effects are not as great, and to never skip
doses of any of the meds. When taking Crixivan, drink A LOT of
water to prevent from getting kidney stones.
Mr. Long is taking several vitamin and herbal supplements. Find
out why someone with AIDS might take each of the supplements.
What would you tell Mr. Long about these supplements? Do they
pose any risk? Use the following table to organize your answers.
Supplement
Vitamin C
Vitamin E
Ginseng
Milk thistle
Echinacea
Proposed Use in HIV/AIDS
Potential Risk
Antioxidant that scavenges for free
radicals, stimulates collagen to repair
tissues, and creates homeostasis in stressed
conditions.
Enhances the immune system’s response to
infection.
May increase CD4+ and CD8+ cell counts.
Kidney stones can form
from too much Vitamin C.
Vitamin C may impair
lymphocyte function.
May raise liver enzymes.
Protects the liver by regenerating new liver
cells destroyed from medications.
Stimulates the immune system.
Multivitamin A multivitamin is useful in replenishing all
nutrients that HIV patients are deficient in.
Many doctors recommend multivitamins as
part of treatment.
May raise blood pressure
over time.
May cause mild diarrhea.
Has been shown to increase
TNF-alpha which
progresses HIV.
Toxicity.
After evaluating Mr. Long’s medical record, identify three specific
nutritional problems that he is experiencing. Then identify
appropriate goal(s) for each problem. Outline a minimum of one
intervention you would recommend to assist this patient in meeting
each goal.
Problem
Feels exhausted and
weak
Sore mouth and throat
Goal
Increase nutrientdense calories.
Medications
Weight loss
Increase protein and
calories.
Intervention
Set up meals through
meal planning.
Set up a regimen and
discuss interactions of
each.
Discuss eating more
snacks throughout the
day.
17. Patients with AIDS are at increased risk for infection. What
nutritional practices would you teach Mr. Long to help him prevent
illness related to food or water intake?
I would advise Mr. Long to wash his hands with soap and water before
eating everytime so he wouldn’t get an infection from the germs on his
hands. Since his immune system is suppressed, he will have a greater
chance of catching these little illnesses. I would advise Mr. Long to
wash all fruits and vegetables thoroughly, as well as raw fish, chicken,
and meat. I would then have him wash right after handling these
meats. Mr. Long needs to make sure that meat, eggs, and fish are well
cooked before eating. This will prevent microbes from the food to
enter the body. Mr. Long should drink eight to ten glasses of filtered
water each day and nothing from the garden hose or from a well that
are sources of microorganisms and infection.
18. Why is exercise important as a component of the nutritional care
plan? What general recommendations could you give to Mr. Long
regarding physical activity?
Exercise has been shown to slow down the rate of HIV in many
patients. I would advise Mr. Long to speak with his doctor before
exercising. With doctor’s orders, I would tell Mr. Long to start out
slowly with exercising. Aerobic exercise is beneficial to begin with to
strengthen your body. After you are comfortable with aerobic
exercise, add in a weight lifting routine. The key to weight lifting is
to lift one day and rest that group of muscles the next. If Mr. Long
is
feeling sick or weak he should either exercise less or stop for a while.