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HIV/AIDS Case Study
Name: Dawn Ortiz
MR is a 38-year-old man who presented to the outpatient clinic with weight loss. He
was in his usual state of health until 3 years ago, when he presented to an AIDS Service
Organization (ASO) for an HIV test, shortly after his brother died of AIDS. When the
results came back positive, he was provided with a list of physicians and clinics for
follow-up care. However, he stated that he felt well at that time and remained without
complaints until 6 months before this presentation.
MR works in the construction industry as a finish carpenter. His daily activities were
becoming increasingly limited by the several bouts of watery diarrhea, which was
associated with nausea. MR compensated by reducing his food intake. After several
days of decreased intake, his diarrhea would decrease, but he became weak and
ultimately lost his appetite. His job was threatened by frequent absenteeism because of
weakness and diarrhea.
MR noted additional weight loss and loose-fitting clothes. He denied fever, chills, night
sweats, or muscle or joint pain.
Usual Dietary Intake
Food Intake: Primarily crackers, rehydrating sports drinks and juices.
Approximately 500 calories/day over the past 2 weeks.
Alcohol Intake: none recently
Tobacco: None
IV drug use: None
Body Composition Data
Parameter
Fat-free mass (lbs)
Body cell mass (lbs)
Extracellular tissue (lbs)
Fat (lbs)
Mid-upper arm circumference
Triceps fatfold (%)
Patient’s Values
105.7
48.1
54.1
15
27.5 (5th%)
4 mm (<5th%)
Normal Value
>102.3
>55.4
47-53
12-24
30-5-34.2 (25-75th%)
8-16 mm (25-75th%)
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Physical Examination
Vital Signs
Temperature: 97.0° F
Heart rate: 100 BPM
Respiration: 15 BPM
Blood Pressure: 100/60 mm Hg
Height: 5’6”
Current weight: 117#
Usual weight (6 weeks ago): 145#
% weight change: 19%
BMI: 18.9 kg/m²
General: thin, cachectic man in no apparent distress
Skin: cold, dry
Head/neck: bilateral temporal wasting and nasolabial fat loss, thin hair
Mouth: gums red around tooth edges
Cardiac: normal
Abdomen: bowel sounds present, scaphoid, soft, nontender, no organomegaly
Extremities: interosseous muscle wasting bilaterally
Neurologic: nonfocal grossly
Laboratory Data
HIV viral load: >500,000 copies/mL
CD4 count: 50 cells/mm³
Albumin: 3.4 g/dL
Hgb: 10.0 g/dL
Hct: 31%
ALT: 22 U/L
AST: 22 U/L
Alkaline Phosphatase: 160 IU/L
Total cholesterol: 85 mg/dL
LDL cholesterol: 60 mg/dL
HDL cholesterol: 20 mg/dL
Triglycerides: 300 mg/dL
Glucose: 120 mg/dL
Testosterone: 300 ng/dL
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Case Questions:
1.
Compare MR’s weight and body composition to appropriate goal levels.
What do the results suggest for his level of wasting and medical problems?
MR qualifies as an AIDS patient, because he has lost 28#, 20% weight loss with
diarrhea in 6 weeks. MR’s cell mass compartment has been depleted by 16#,
which is 15% under ideal (a 5% loss of body cell mass falls under the definition of
wasting). Although MR’s fat free mass is adequate, his fat weight, upper arm
circumference and tricep fatfold are below normal. MR’s poor food intake and
excessive diarrhea may set his body into a state of starvation. His elevated
electrolyte labs indicate infection, however his body may be too weak to
produce the normal inflammatory response.
2.
What factors may have contributed to MR’s wasting?
MR’s wasting can be attributed to the excessive diarrhea he is experiencing,
resulting in fluid loss and nutrient malabsorption. MR’s low testosterone level
may also be a cause of his body cell mass loss. The HIV viral load and low CD4
count increases risk for infection and contributes to weight loss.
3.
What is your overall impression of MR’s nutritional status? Calculate MR’s
calorie and protein needs (show your calculations).
MR is malnourished and symptomatic. His low albumin and cholesterol with
anemia are indicative of advanced HIV. Adequate nutrition therapy is necessary
for his body to support anti-HIV medications. The MNT goal should be to restore
his body weight back to his UBW of 145#. However, MR is at risk for refeeding
syndrome since his appetite and intake has been extremely low for the past 6
weeks. He should start with a low residue diet consisting of small frequent
meals, consuming 50% of his resting energy expenditure.
Harris-Benedict Equations (calories/day):
Male: (66.5 + 13.8 X 53) + (5.0 X 173) - (6.8 X 38)
=798 + 865 – 258
= 1405 x .50
=703 kcal to start
Kcal should be advanced slowly by 10% as tolerated, until a goal of 35-40 kcal/kg
(1855-2120 kcal/day)
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Protein should be 1.5-2 g/kg/day, 80 g/day. (80 – 106 g)
4.
Define HIV and list the stages of HIV infection.
HIV: Acronym for the Human Immunodeficiency Virus, the cause of AIDS
(acquired immunodeficiency syndrome), is an incurable, retrovirus affecting the
immune system.
Stages of HIV:
1. Acute HIV infection—Virus replicates, CD4+ cell counts are increased to help
fight virus.
2. Clinical latency—Virus continues to replicate, CD4+ cell counts decrease
because virus has taken over, no symptoms.
3. Symptomatic HIV infection—CD4+ cell counts lower, symptoms are present;
fever, diarrhea, weight loss and muscle wasting.
4. Progression to AIDS—Extremely low CD4+ cell count (below 200 ml cubed),
AIDS defining condition, viral and bacterial infections, and cancers present.
5.
What are the primary routes of HIV transmission?
HIV is transmitted by blood (IV drug use, transfusions), sexually (semen, vaginal
fluid), breast feeding or amniotic fluid.
6.
What criteria must be met to progress from HIV to AIDS?
CD4 lymphocyte < 200 cells/mm3 (or CD4 lymphocyte <14%) with +HIV test or a
diagnosis of an AIDS-defining condition.
7.
What is HAART? What are the goals of this therapy?
Highly active antiretroviral therapy is aggressive treatment to suppress HIV viral
replication and the progression of HIV disease. This is the combination of
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medications and appropriate MNT to reduce wasting, opportunistic infections
and morbidity of the disease. HAART prolongs the life of HIV patients.
8.
For each of the following classes of HIV medications, give their mechanism of
action, names of medications and possible side effects:
A.
B.
C.
D.
9.
Protease Inhibitors (PI): PIs block HIV protease, an enzyme HIV needs
to make copies of itself. Examples are atazanavir, darunavir and
fosamprenavir, possible side effects for this class of drugs include,
heart rhythm problems, severe rash, lipodystrophy, hyperglycemia,
liver problems, and life-threatening drug interactions.
Nucleoside Reverse Transcriptase Inhibitors (NRTI): NRTIs block
reverse transcriptase, an enzyme HIV needs to make copies of itself.
Examples are abacavir, didanosine and emtricitabine, possible side
effects for this class of drugs include, allergic reactions, lactic acidosis,
lipodystrophy, increased risk of heart attack and liver problems
Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI): NNRTIs
bind to and later alter reverse transcriptase, an enzyme HIV needs to
make copies of itself. Examples are delavirdine, efavirenz and
etravirine, possible side effects for this drug class include, severe rash,
allergic reactions and lipodystrophy.
Fusion Inhibitors: Fusion inhibitors block HIV from entering the CD4
cells of the immune system. Example is enfuvirtide, possible side
effects include, severe allergic reaction, severe or infected injection
sites, and possibly pneumonia.
Define each of the following opportunistic infections:
A.
B.
C.
D.
E.
F.
Candida: yeast infection associated with sore mouth and
oral/esophageal ulcers, pain with eating and/or swallowing.
Cryptosporidia: parasite that causes the diarrheal disease.
Mycobacterium Avium Complex (MAC): common bacteria found in
the body that cause infection in people with HIV.
Microsporidia: infection caused by spore-forming parasites.
Cytomegalovirus (CMV): herpes virus, symptoms only appear in
people with a weakened immune system.
Cryptococcal Meningitis: infection and inflammation of the meninges
(membranes that cover the spinal cord and brain), caused by bacteria,
fungi, and viruses.
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G.
H.
I.
J.
10.
Pneumocystitis Pneumonia (PCP): serious infection that causes
inflammation and fluid buildup in the lungs, caused by fungus
transmitted in the air, only harmful to individuals with weakened
immune systems.
Tuberculosis (TB): spread by airborne germs, usually affects the lungs,
but may also cause damage to the brain, kidneys and spine.
Kaposi’s Sarcoma: rapidly developing form of cancer common in
HIV/AIDS patients, causes patches and lesions of abnormal tissue to
grow under the skin, in the lining of the mouth, nose, and throat or in
other organs.
Non-Hodgkin’s Lymphoma: cancer characterized by abnormal
lymphocytes, causing large lymph nodes, resulting in fever weight
loss.
What is the CDC definition of HIV Wasting?
According to the CDC, the definition of AIDS includes greater than 10% weight
loss with diarrhea or fever for more than 30 days.
11.
What is the Ryan White HIV/AIDS Treatment Modernization Act?
Amendment to the Public Health Service Act to revise and extend the program
for providing life-saving care for those with HIV/AIDS. The Ryan White
Comprehensive AIDS Resources Emergency Act (1990) was the largest federally
funded program in the US for people living with HIV/AIDS. Federal funds are
awarded to agencies located around the country. Current funding $2.1 billion.
Parts A and D provide funds for MNT by Registered Dietitian. Ryan White was
diagnosed with AIDS after treatment for hemophilia and fought AIDS-related
discrimination.
12.
Based on MR’s nutritional evaluation, what medical nutrition therapy is
appropriate at this time?
These are the symptomatic, HIV nutrition therapy guidelines at my hospital. MR
would benefit from this MNT.
ORAL
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Maintain diet appropriate for the patient’s condition (high calorie/protein
diet with adequate nutritional supplementation).
Small, frequent feedings usually are better tolerated.
Avoid food odors if patient experiencing nausea.
Nutrient-dense snacks may be beneficial. Add protein powders and
glucose polymers if desired.
Lactose or gluten may not be tolerated by some patients, resulting in
diarrhea. Sucrose and d-xylose may also contribute to diarrhea.
Supplements containing Omega 3 fatty acids +/or MCT oil may be useful.
With diarrhea, use small meals and avoid extremes in temperatures
(room temperature is best). Replace electrolytes, decrease fat and
lactose, and avoid excesses of caffeine, alcohol and bran.
Optimize mealtime scheduling to reduce mealtime fatigue.
Make changes in diet consistency to counteract such problems as
dysphagia and difficulty in chewing.
Maintain low fat, low cholesterol diet if hyperlipidemic.
Reglan, Megace, Remeron or Marinol may be useful to stimulate
appetite.
ENTERAL NUTRITION
Use tube feeding if warranted by status. Standard formulas are appropriate for
most HIV and AIDS patients, but can use a semi-elemental, low fat formula if
malabsorption and/or high triglycerides are present. Studies suggest that
immune enhancing enteral formulas may help promote host defense and weight
gain.
PARENTERAL NUTRITION
TPN is indicated if severe weight loss coupled with severe GI dysfunction and
inability to tolerate oral or enteral feeds are present. Monitor labs closely
especially triglycerides.
MULTIVITAMINS/MINERALS/SUPPLEMENTS
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A general multivitamin-mineral supplement that meets 100% US RDI is
recommended. May need to increase water-soluble vitamins if
malabsorption present; maintain fat soluble vitamins at RDA levels.
Beware of excesses of iron, zinc, vitamin E and PUFA’s because of their
effects on immunity when taken in large doses. Parenteral iron and zinc
are not recommended in cachectic patients or in sepsis.
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13.
Research is being conducted on the use of arginine for promoting weight
gain and immune function, glutamine for promoting lean tissue gain, and
omega 3 fatty acids in enhancing immune function but compelling
evidence to support their use is still lacking.
Glutamine two or three times a day may be useful for persistent
malabsorption/diarrhea, and has shown some benefit as a swish and
swallow solution for mouth pain/sores.
Anabolic steroids such as testosterone, oxandrolone, growth hormone
may be used to promote lean body mass repletion.
Eating calcium-rich and vitamin D-fortified foods and supplementing with
500-1200 mg/day calcium may be beneficial in avoiding complications of
osteopenia and osteoporosis.
Once MR is being treated with antiviral medications and about to be
discharged, what follow-up recommendations would be appropriate?
MR’s weight and body cell mass should be closely monitored. Lab values
should be obtained frequently to make sure his nutrition needs are being
met and testosterone levels have improved. A common side effect of
antiretroviral medications is lipodystrophy, which should be monitored.
Exercise is also encouraged for MR.
References
Hark L., Darwin D., and Morrison G. Medical Nutrition and Disease: A Case-Based
Approach, 5th. Ed. Philadelphia, PA: Wiley-Blackwell; 2014: 313-16.
AIDS Info: Offering Information on HIV/AIDS Prevention, Treatment and Research.
http://aidsinfo.nih.gov/education-materials/fact-sheets/21/58/fda-approved-hivmedicines. Site updated November 2014. Accessed on November 26, 2014.