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

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Case 11: June 2006Admitted 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 200,0002

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

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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 hospital4

Case 11: June 2006Management:

• 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

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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

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Case 11: June 20061 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 2°HIV

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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

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

1. When he was seen with persistent lymphopenia? (2000)

2. When he was admitted with watery diarrhoea? (2000)

3. When he was admitted with cerebellar infarct? (2001)

4. When he was seen for peripheral neuropathy? (2001)

5. When he was admitted with weight loss and oesophagitis? (2003)

6. When he was admitted with a fracture and disclosed living with male partner? (2004)

7. When he was admitted with recurrent LRTI? (2005)

8. When he was seen for “non-HIV-related CMV retinitis”? (2006)

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Who can test?

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Who to test?

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Rates of HIV-infected persons accessingHIV care by area of residence, 2007

Source: Health Protection Agency, www.hpa.org.uk

Who to test?

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Who to test?

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Who to test?

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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

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8 missed opportunities – 5 in ED - to diagnose HIV before terminal presentation! If current guidelines used, HIV could have been diagnosed 6 years earlier

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 >1/1000 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

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Also contains

UK National Guidelines for HIV Testing 2008

from BASHH/BHIVA/BIS

Available from:

enquiries@medfash.bma.org.uk or 020 7383 6345