Andrea Sigrist
Clinical Case Scenario Presentation
KNH 411
November 20, 2012
Case 35: HIV
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 is transmitted from one infected person to another by blood, semen, vaginal
secretions, and breast milk. It can be transmitted by sexual contact, both
intercourse and oral sex, direct blood contact, including sharing needles, blood
transfusions, and accidents in health care settings, and from mother to child
during breast feeding. Mr. Long used to work as a nurse in a dialysis center, so
he could have contracted it at work from dealing with an infected patient. He also
admitted to having multiple sexual partners of the opposite sex, so he could have
also contracted the disease from a partner. He also admits to using recreational
drugs, though he does not specific what drugs or how he is taking them, but he
can contract HIV by sharing needles with an infected person.
AIDS.org (2012). AIDS Information, Education, Action, Awareness | How is HIV
Transmitted? AIDS Information, Education, Action, Awareness | HIV, AIDS Facts.
Retrieved from http://www.aids.org/topics/aids-faqs/how-is-hiv-transmitted/
2. Mr. Long says he found out he was HIV positive four years ago. Why is he only
symptomatic now?
After being infected with HIV, many patients experience flu-like symptoms that go
away within a few weeks and their body behaves as usual. The progression of
the disease varies from person to person, so patients may not notice symptoms
again for more than ten years. The amount of time before a person notices
symptoms depends on how active the virus is in that particular person and how
fast the virus multiples, infects, and then kills the cells of the immune system.
The virus has taken four years to kill enough cells to show symptoms.
WebMD (2007). HIV & AIDS Symptoms: Weight Loss, Lack of Energy, Fever,
and More. WebMD - Better information. Better health. Retrieved from
http://www.webmd.com/hiv-aids/guide/hiv-symptoms
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 means a patient has positive results or high levels of antibodies on
the results of a serological examination. The Western Blot test is done to detect
specific proteins in a sample. The test is done by sorting proteins by length on a
gel and then seeing if any of the proteins will stick to a specific antibody. If a
person is HIV positive, they will have antibodies against one of the envelope
proteins and one of the core proteins, or against one of the enzymes. ELISA
(enzyme-linked immunosorbent assay) is done to look at how much of an
antibody is in a sample or how much protein is bound by an antibody. A 96-well
plate is used to test the blood and see if a specific antigen is linked to an
enzyme. If a person is HIV positive, the serum with change to a different color.
Boskey, Ph. D., E. (2011, September 6). HIV Testing - How Does a Western Blot HIV
Test Work? Sexually Transmitted Diseases - STDs. Retrieved from
http://std.about.com/od/HIVTesting/f/How-Does-A-Western-Blot-Hiv-Test-Work.htm
Medline Plus (2010, October 30). ELISA: MedlinePlus Medical Encyclopedia. National
Library of Medicine - National Institutes of Health. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/003332.htm
4. What is thrush, and why might Mr. Long have this condition?
Thrush is a yeast infection of the mucous membrane lining the mouth and tongue.
Mr. Long might have this condition because the HIV makes his immune system very
week. His CD4 cell levels, which help fight off diseases, are very low, so he is not
able to fight off the fungus as easily.
Carter, M. (2011, April 11). HIV & AIDS Information: Candida (thrush). HIV & AIDS
Information: Home. Retrieved from http://www.aidsmap.com/Candidathrush/page/1044820/
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?
One of the major nutritional complications associated with HIV and AIDS is
malnutrition. Because of a weakened immune system, infections, and sideeffects of treatment, patients may experience loss of appetite, diarrhea,
nausea, vomiting, and mouth sores, which cause a patient to stop eating or
lose any energy and nutrients they take in. Their nutrient metabolism changes,
positive and negative acute-phase proteins are produced which affect macroand micronutrient absorption, and some micronutrient and mineral levels
decrease. Mr. Long has mouth and throat sores, and describes his appetite as
“not normal”, both of which are affecting his ability to eat and causing him to
lose weight.
Health24 (n.d.). Nutrition and Aids, HIV/Aids - Health24. Health24 - South
Africa's premier health and wellness site, provides world-class information and
interactive tools for a healthy lifestyle. Retrieved from
http://www.health24.com/medical/Condition_centres/777-792-814-1769.asp
Pg. 750
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?
Mr. Long has thrush, has lost less than 10% of his body weight, and his T-cells,
helper t-cells, and t-suppressor cells are all well below normal range. These
symptoms along with herpes zoster, minor mucocutaneous manifestations,
recurrent bacterial upper respiratory tract infections, and fungal infections, are
criteria for HIV Clinical Stage 2.
Pg. 744
7. Evaluate the patient’s anthropometric information.
a. Calculate %UBW and BMI.
% UBW = 151lbs/ 165lbs x 100 = 91.5%
BMI = 68.64kg/ (1.8542m)(1.8542m) = 19.96
b. Compare the TSF to population standards. What does this comparison
mean? Is this a viable comparison?
Mr. Long’s TSF: 7mm
Normal TSF measurement: 15.1 to 85
Mr. Long is below average and his measurement is so low that there is
likely total body wasting. Because his measurement is so low, I think other
tests should be used in addition. A skin fold test would help compare him
to the rest of the population.
Pg. 51
c. Using MAC and TSF, calculate upper arm muscle area. What can you
infer from this calculation?
AMA for males in mm2= [MAC (cm) - (3.14 x TSF in cm)]2 - 10
4 x 3.14
[25.4 – (3.14 x .07)]2 – 10
4 x 3.14
= 634.042472– 10
12.56
= 40.48 mm2
Adequate muscle mass for a man is at least 54. Mr. Long is only at 40.48,
which puts him in the marginal category. He is within 75%, so this
measurement does not cause a lot of concern.
Pg. 50
d. Mr. Long’s body fat percentage is 12.5%. What does this mean? Compare
to standards.
Healthy body fat percentages for men ages 20-39 are 8% to 19%. Mr.
Long is in the middle of this range, so he is considered to have a healthy
amount of body fat.
Fit Day (2011). What is a Normal Body Fat Percentage? / Fitness / Weight
Loss. FitDay - Free Weight Loss and Diet Journal. Retrieved from
http://www.fitday.com/fitness-articles/fitness/weight-loss/what-is-a-normalbody-fat-percentage.html
e. Summarize Mr. Long’s nutritional risk (if any) from your assessment of
anthropometric information.
Mr. Long’s nutritional status is not good and he is at risk for being
considered unhealthy. He BMI is lower than a man of his age should be
and he is losing muscle mass.
8. 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 diet tracker, such as Fitday.com to assess his diet because it will
calculate the macronutrients he is consuming and intake what he is consuming
too much and too little of. I enter Mr. Long’s diet into the site and it calculated
that he consumed about 1,979 calories, 64.8 grams of fat, 228.4 grams of
carbohydrate, 71.3 grams of protein a day. His diet was below the RDA for a
man of his age and stature. Mr. Long is lacking adequate amounts of vitamin A,
B6, B12, C, D, E, calcium, copper, iron, magnesium, manganese, niacin,
phosphorus, potassium, riboflavin, selenium, sodium, thiamin, and zinc. A food
journal and site like Fitday.com could help a dietitian monitor his diet and make
sure he is consuming adequate nutrition.
FitDay. (2012). FitDay - Free Weight Loss and Diet Journal. Retrieved from
http://www.fitday.com/fitness/FoodLog.html?_a_Date=1322611200.&_v_View_
FoodL ogSummaryTabs-Focus=Nutri
9. Mr. Long states that he consumes alcohol several times a week. Are there any
contraindications for alcohol consumption for him?
The main contradiction of Mr. Long’s alcohol use is its interaction with the
medications he was just prescribed. Alcohol can slow down the effectiveness of
antiretroviral therapies, which will affect the progression of the HIV infection.
Cooper, C. L., & Cameron, D. W. (2005). Effect of Alcohol Use and Highly Active
Antiretroviral Therapy on Plasma Levels of Hepatitis C Virus (HCV) in Patients
Coinfected with HIV and HCV. Oxford Journals | Medicine | Clinical Infectious
Diseases. Retrieved from
http://cid.oxfordjournals.org/content/41/Supplement_1/S105.full
10. 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?
The labs used to monitor his HIV are CD4 (helper t-cells) and CD8 (suppressor
t-cells). These cells help the body fight off diseases and the level indicates how
strong a person’s immune system is. I would explain to Mr. Long that these
levels along with a Viral load test can be used as an indication of the
progression of the disease and evaluate if the treatment is effective. Mr. Long’s
CD4 and CD8 count are very low and the viral load is very high. The Centers
for Disease Control and Prevention consider a person with HIV to have
progressed to AIDS when they have a CD4 count below 200 cells/mm 3, and Mr.
Longs count is 157 cells/mm3 indicating he now has AIDS.
AIDS (2012). AIDS Information, Education, Action, Awareness | CD4 (T-CELL)
TESTS. AIDS Information, Education, Action, Awareness | HIV, AIDS Facts.
Retrieved from http://www.aids.org/topics/aids-factsheets/aids-backgroundinformation/what-is-aids/hiv-testing/cd4-t-cell-tests/
11. What laboratory values can be used to evaluate nutritional status? Are there
any for Mr. Long that identify nutritional risk?
The laboratory values used to evaluate his nutritional status are albumin,
prealbumin, and BUN tests. Albumin and prealbumin levels shows how much
protein is in the blood, which can indicate if there are problems with the kidney
or liver due to the HIV. The BUN tests show hydration levels and how well the
kidneys are functioning. His albumin and BUN levels are normal values, but his
prealbumin level is slightly lower than normal.
12. Calculate Mr. Long’s optimal energy and protein intake. How does this compare
to his diet history?
Energy needs:
10x wt (kg) + 6.25 x ht (cm) – 5 x age (yrs) + 5
10 x 68.64 + 6.25 x 185.42 – 5 x 32 + 5
686.4 + 1158.875 – 165 = 1,680.275
EER: 662- (9.53 x 32) + 1.7(15.91 x 68.64 + 539.6 x 1.8542) = 3,914.4
Protein needs:
3,914.4 x 0.15= 587.16/4 = 146.79g
Mr. Long is not consuming enough nutrient-dense foods and is consuming a lot
of empty calories. He is not eating adequate calories, protein, carbohydrates or
fat.
13. What other information would you want to obtain from Mr. Long in order to fully
evaluate his nutritional status?
I would also like to know why he is not able to work right now, what his daily
activity level is, and find out if he is sleeping through the night to get an
adequate amount of sleep. I would like Mr. Long to track his diet for an entire
week and would like to know what kind of recreational drugs he is doing.
14. Mr. Long started on three medications that he will be discharged on.
a. Identify these medications and the purpose of each.
1. AZT (ziduvudine) – helps to decrease the amount of HIV in the body so
the immune system can work better. It also lowers the changes of getting
HIV complications and improves quality of life.
2. Crixivan (indinavir) - helps to decrease the amount of HIV in the body
so the immune system can work better. It also lowers the changes of
getting HIV complications and improves quality of life.
3. Epivir (lamivudine) - helps to decrease the amount of HIV in the body so
the immune system can work better. It also lowers the changes of getting
HIV complications and improves quality of life.
b. Are there any specific drug-nutrient interactions to be concerned about?
Explain.
1. AZT (ziduvudine) – herbal products such as ginseng and milk thistle
because they may interact.
2. Crixivan (indinavir) – It should not be taken with meals high in fat,
calories, or protein because this may decrease its effects. He should also
avoid grapefruit, herbal supplements, and St. John’s wort.
3. Epivir (lamivudine) – Alcohol may increase liver problem risks or lead to
pancreatitis. Herbal products also interact with this medication.
c. Is there specific information you would want Mr. Long to know about
taking these medications?
Mr. Long should be careful about taking herbal products because of the
interactions with ziduvudine and should avoid alcohol because it may
lessen the effectiveness of the medications and be too hard on the
kidneys. Indinavir should be taken with a full glass of water and on an
empty stomach. He should also make sure he is consuming at least 6
glasses of water a day to reduce the risk of developing kidney stones.
Epivir must be taken exactly as prescribed because changing the dose or
skipping a dose may increase the amount of the virus, make the infection
more difficult to treat, or worsen the side effects.
Web MD (2012). Drug Search from WebMD. WebMD - Better information.
Better health. Retrieved from
http://www.webmd.com/drugs/search.aspx?stype=drug&query=lamivudine
+Oral&submitDetailsTop.x=0&submitDetailsTop.y=0&source=2
15. 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
Proposed use in HIV/AIDS
Vitamin C
Improve antioxidant capacity,
increases iron absorption from nonheme sources
Vitamin E
Vitamin E may protect against toxicity
and side effects from AZT
(antiretroviral medications)
Ginseng
Milk thistle
Echinacea
Multivitamin
Potential Risk
Increases urinary losses
of oxalate and calcium
Can interfere with blood
clotting. Cause nausea,
diarrhea, muscle
weakness, fatigue
Has anti-stress and anti-fatigue
morning diarrhea,
effects; May contain a protein with
insomnia, nervousness,
anti-HIV activity
depression, confusion,
skin rashes and high
blood pressure
May prevent liver damage caused by
Upset stomach, diarrhea,
HIV medications
bloating, gas
Anticancer, immunostimulatory;
May inhibit metabolism
stimulate immune system and promote of drugs using the
CD4 cell activation
cytochrome P 450
enzyme pathway
Slows disease progression, increases None
CD4 count, lowers viral load values
Pg. 749
The Body (2005, January). Herbs, Supplements and HIV - TheBody.com. The
Complete HIV/AIDS Resource - TheBody.com. Retrieved from
http://www.thebody.com/content/art5003.html#chart
16. 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
Can only tolerate a small
amount of milk
Does not like vegetables
Goal
Consume more daily or a
dairy substitute
Consume more
vegetables
Intervention
Suggest trying a soy or
almond milk
Hide vegetables in other
dishes, drink vegetable
beverages that hide the
taste
Consumes a lot of sugar
Reduce sugar intake
Consumes alcohol
several times a week
Eliminate alcohol
Get him to stop buying
processed snacks and
pop, use sugar substitute
Suggest other drinks,
suggest a program if he
is unable to stop
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 good or water
intake?
Since his immune system is so weak and he can contract infections easily, I
would teach him food safety to avoid food-borne illnesses and infections. I
would tell him to make sure he washes his hands before and after preparing
and eating food, cooking all meat and products to the right temperature, wash
all fruits and vegetables before eating, knife safety, and to only drink purified
water.
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?
An exercise program of aerobic and resistance training is important part of
nutritional care because it can improve muscle health, strength, effect of
anabolic therapies, insulin sensitivity and endurance, as well as increase HDL
C. Resistance training can restore BCM from weight loss and wasting, prevent
BCM volume and function loss, and improve muscle function. Aerobic exercise
can restore normal activity level, reduce effect of insulin resistance on body
shape and fat changes, and prevent and treat adjunct for cardiovascular health
efforts. I would recommend Mr. Long start an exercise program, including both
resistance training and aerobic exercise, at least three times a week. I would
tell him to only do what his body and health will allow him, and consult his
doctor about any complications during exercise.
Pg. 760-761