Case 11

1
Case 11

• 71 year-old white male
• From the UK
• Had lived in London
• Retried to South Coast town
• Ex-smoker
• EtOH - 8 units day wine/spirits
• Unmarried, lived alone

2
Case 11 June 2006

• Admitted via Ophthalmology with
• Probable HIV-related peripheral neuropathy
• Probable Pneumocystis jirovecii pneumonia
• CMV retinitis
• Sexual history
• Friend long-term male partner
• no UPAI 15 years
• Initial investigations
• BAL confirmed PCP
• CD4 7 VL 200,000

3
Case 11 PMH

• 2000 Seen in Haematology for persisting
  lymphopenia
• 2000 Admitted with weight loss, watery diarrhoea
• 2001 Admitted with cerebellar infarct
• 2001 Seen in Neurology OPD (3 in London, 1
  elsewhere)
• for peripheral neuropathy - unknown cause
• 2003 Admitted with weight loss, OGD
  oesophaghitis
• 2004 Admitted with fractured right neck of femur
• lymphocytes 0.5 (1.3-3.5)
• multiple mouth ulcers
• candida on mouth swab
• 2005 Recurrent LRTIs throughout 2005

4
Case 11 June 2006

• Seen in Ophthalmology OPD
• vitreous detachment in left eye
• 2/12 history of acute onset unilateral cloudy
  vision
• OE
• retinal necrosis
• features characteristic of CMV retinitis
• SOB
• Refractory to antibiotics from GP
• Admitted to hospital

5
Case 11 June 2006

• Management
• Left vitrectomy and intraocular foscarnet
• D/w Genitourinary Medicine team
• What is the current treatment for
  non-HIV-related CMV retinitis?
• GUM team
• Could this be HIV-related?
• Investigations
• Rapid strip HIV test reactive
• Confirmatory 4th generation HIV test positive

6
Case 11 June 2006

• Further management
• CMV retinitis
• Intraocular foscarnet
• Initiated on Valgancyclovir 900mg po bd
• 21/7 ?maintenance
• PCP
• treated empirically with Co-trimoxazole, dose
  120mg/kg bd
• 21/7 ?prophylaxis
• HIV-related neuropathy
• Prednisolone 60mg po od
• Antiretroviral therapy initiated

7
Case 11 June 2006

• 1 day prior to planned discharge
• Septicaemic shock
• Died despite
• vigorous fluid resuscitation
• broad spectrum antibiotic cover
• ITU admission
• ventilatory support
• maximal inotropic support
• Blood cultures grew Klebsiella terrigena
• Cause of death
• 1a gram negative sepsis
• 1b multi organ failure
• 1c immunosupression 2HIV

8
Case 11 summary

• 2000 Haematology OPD, persisting lymphopenia
• 2000 Gen. med. admission, watery diarrhoea,
  weight loss
• 2001 General medical admission, cerebellar
  infarct
• 2001 Neurology OPD, peripheral neuropathy -
  unknown cause
• 2003 Gen. med. admission, weight loss - OGD
  oesophagitis
• 2004 Fracture NOF, low lymphocytes, oral
  candida - recorded in ED notes lives with male
  partner
• 2005 General medical admission, LRTI low
  lymphocytes
• 2006 Ophthalmology OPD non-HIV related CMV
  retinitis
• 2006 HIV diagnosed PCP CD4 7 VL 200,000

9
Q At which of his healthcare interactions could
HIV testing have been undertaken?

• When he was seen with persistent lymphopenia?
  (2000)
• When he was admitted with watery diarrhoea?
  (2000)
• When he was admitted with cerebellar infarct?
  (2001)
• When he was seen for peripheral neuropathy?
  (2001)
• When he was admitted with weight loss and
  oesophagitis? (2003)
• When he was admitted with a fracture and
  disclosed living with male partner? (2004)
• When he was admitted with recurrent LRTI? (2005)
• When he was seen for non-HIV-related CMV
  retinitis? (2006)

10
Who can 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
Who to test?
15
Who to test?
16
8 missed opportunities 5 in ED - to diagnose
HIV before terminal presentation! If current
guidelines used, HIV could have been diagnosed 6
years earlier

• 2000 Haematology OPD, persisting lymphopenia
• 2000 Gen. med. admission, watery diarrhoea,
  weight loss
• 2001 General medical admission, cerebellar
  infarct
• 2001 Neurology OPD, peripheral neuropathy -
  unknown cause
• 2003 Gen. med. admission, weight loss - OGD
  oesophagitis
• 2004 Fracture NOF, low lymphocytes, oral
  candida - recorded in ED notes lives with male
  partner
• 2005 General medical admission, LRTI low
  lymphocytes
• 2006 Ophthalmology OPD non-HIV related CMV
  retinitis
• 2006 HIV diagnosed PCP CD4 7 VL 200,000

17
Learning Points

• This patient had numerous investigations and 5
  admissions over 6 years, causing him much
  distress and costing the NHS thousands of pounds
• Some patients might not disclose risk factors for
  HIV on routine questioning in Outpatients even if
  the right questions are asked
• 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

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Key messages

• Antiretroviral therapy (ART) has transformed
  treatment of HIV infection
• The benefits of early diagnosis of HIV are well
  recognised - not offering HIV testing represents
  a missed opportunity
• UK guidelines recommend universal HIV testing for
  patients from groups at higher risk of HIV
  infection
• UK guidelines recommend screening for HIV in
  adult populations where undiagnosed prevalence is
  gt1/1000 as it has been shown to be cost-effective
• HIV screening should become a routine test on
  presentation of lymphopenia, PUO, chronic
  diarrhoea and weight loss of otherwise unknown
  cause

19
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