Case 6

1
Case 6

• 58 year-old man from North America
• Married
• Recently moved to London

2
Case 6 late 2005

• Registered with GP - new patient check
• Lipids normal
• Random glucose normal
• FBC normal - incidental finding low platelets
• Referred to Haematology OPD

3
Case 6 late 2005

• Seen in Haematology OPD (wife present)
• Investigations
• Platelet count 65 x 109/l (150 - 400 x 109/l)
• No other symptoms
• Patient stated No risk factors for HIV
• HIV test not performed
• Bone marrow aspirate and trephine (megakaryocytes
  present consistent with peripheral
  destruction/consumption)

4
Case 6 late 2005

• Diagnosis
• Auto-immune thrombocytopenia
• Plan
• Observe
• GP to monitor platelet count
• No plan for active treatment

5
Case 6 late 2006

• Patient re-referred by GP to Haematology
• Platelet count 56 x 109/l (150 - 400 x 109/l)
• Weight loss
• Reviewed by Gastroenterologist/Urologist
• OGD, Colonoscopy, Cystoscopy performed NAD
• Patient stated No risk factors for HIV

6
Case 6 late 2006

• HIV test (after counselling) positive
• Patient recalls being bisexual in 1980s/1990s and
  since
• Referral to HIV team
• CD4 146 (5)
• VL 94,000
• No opportunistic infection
• Antiretroviral therapy commenced

7
Case 6 summary

• 2005 Registered with GP, referral, low platelets
• 2005 Seen in Haematology, thrombocytopenia
• 2006 Re-referred to Haematology, low platelets
• 2006 Seen by Gastroenterology and Urology for
  weight loss
• 2006 HIV diagnosed CD4 146 VL 94,000

8
Q At which of his healthcare interactions could
HIV testing have been performed?

• When he registered with his GP and was referred
  to Haematology?
• When he was first seen in Haematology?
• When he was seen by Gastroenterology and Urology
  for weight loss?
• Only after being referred to GUM for counselling
  before HIV testing?

9
Who can test?
10
Who to test?
11
Who to test?
12
Rates of HIV-infected persons accessing HIV care
by area of residence, 2007
Source Health Protection Agency, www.hpa.org.uk
13
Who to test?
14
4 missed opportunities! If current guidelines
used, HIV could have been diagnosed at least 13
months earlier

• 2005 Registered with GP, referral, low platelets
  
• 2005 Seen in Haematology, thrombocytopenia
• 2006 Re-referred to Haematology, low platelets
• 2006 Seen by Gastroenterology and Urology for
  weight loss
• 2006 HIV diagnosed CD4 146 VL 94,000

15
Haematological presentationsin HIV infection
16
Thrombocytopenia in HIV

• Mode of presentation in 10 (Sullivan et al,
  1997)
• Thrombocytopenia in 40 of patients
• Platelet count lt 50 x 109/l in 1 - 5 cases
• Isolated thrombocytopenia
• does not affect overall prognosis (Holzman et al,
  1987)
• May be managed differently from HIV negative
  patients

17
Mechanisms underlying thrombocytopenia

• Reduced production THINK HIV!
• Generalised bone marrow failure
• Selective megakaryocyte defects
• Increased consumption THINK HIV!
• Immune
• Disseminated intravascular coagulation (DIC)
• Thrombotic thrombocytopenia purpura (TTP)
• Abnormal distribution
• Sequestration (splenomegaly infection,
  haemophagocytosis, cirrhosis)
• Dilutional

18
Classification of anaemias
19
Learning Points

• This man did not have an obvious risk factor when
  a medical history was initially taken
• He had put himself at risk in the past but did
  not share this with anyone on routine questioning
  in outpatients as his wife was present
• 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

20
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 is
  gt1/1000 as it has been shown to be cost-effective
• UK guidelines recommend routine opt-out HIV
  testing for patients with thrombocytopenia
• 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

21
Also contains UK National Guidelines for HIV
Testing 2008 from BASHH/BHIVA/BIS
Available from enquiries_at_medfash.bma.org.uk or
020 7383 6345