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Clinicopathologic ConferenceAdvanced Update in HIV Medicine
and Clinical ResearchOctober 1, 2009
Tammy M. Meyers, BA, MBBCh (WITS), FCPaed (SA), Mmed, DTM&H
University of the Witwatersrand Thumbi Ndung'u, DVM, PhD.
Nelson R. Mandela School of Medicine
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“A 7-year-old boy with elevated HIV ribonucleic acid levels despite
antiretroviral medications”
Presentation of Case
Brian C. Zanoni, M.D.
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History of Present Illness
• 7 year old HIV positive child on ART transferred care to Sinikithemba Clinic
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Past Medical History
• Birth history– Full term normal spontaneous vaginal delivery– 3.4 Kg– Mother with prenatal care but no HIV testing– Breastfed for 3 months– Received all routine immunizations
• Including BCG
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History of Present Illness
• At age 3 hospitalized for pneumonia– Clinically diagnosed with pulmonary TB– Completed 6 months of RIF, INH, PZA
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History of Present Illness
• 5 years 10 months old admitted for respiratory distress– Mantoux negative– HIV positive– Treated with ceftriaxone, clarithromycin,
trimethoprim-sulfamethoxazole (TMP/SMX), albuterol (salbutamol), and hydrocortisone
• No improvement
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History of Present Illness
• Admission continued– CD4: 9 / 1%
– VL: 2.2 million copies / ml– Weight: 14 Kg (<5%)– After 5 days of no improvement started on
RIF, INH, PZA for presumptive TB– Began HAART with AZT, 3TC, Ritonavir– Discharged on day 11
• Continued TMP/SMX, TB treatment, and ART
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History of Present Illness
• 4 months later– Developed a supraclavicular abscess
• No response to antibiotics• I and D
– Culture: No growth (bacterial or mycobacterial)– Pathology: Caseating granulomas with necrosis
» Consistent with TB
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History of Present Illness
• 6 months after admission and ART/TB Treatment– Supraclavicular node resolved– TB treatment stopped (6 months completed)
– CD4: 236 / 6% (↑ 9 / 1% at baseline)
– VL: 3342– Weight: 15 kg (~3%)
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History of Present Illness
• After 18 months on ART– Unable to continue with private physician for
financial reasons– Transferred to McCord Hospital Sinikithemba
Clinic– Mother reported good adherence with ART
and TMP/SMX– Patient was unaware of his HIV status
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Social/Family History
• Father died of unknown illness when patient was an infant
• Mother tested HIV positive after diagnosis of patient
• Siblings tested HIV negative
• No known TB contacts
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Presentation to Sinikithemba
• Physical exam– Weight < 5%– Axillary adenopathy– Otherwise normal
• Preliminary management– AZT dose increased– 3TC dose increased– Ritonavir changed to lopinavir/ritonavir– TMP/SMX continued
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Lab Results
• 18 Months on ART– CD4: 146 / 6.1 %
– VL: 4300– Hb: 10.6 MCV 96– LFTs: Normal
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Follow-up
• 5 months after presentation to Sinikithemba– Mother reported good adherence
• No side effects
– CD4: 471 / 17.9%
– VL: 22,000 copies / ml– Weight: 17.39 Kg (<5%)
• A diagnostic test was performed
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Differential Diagnosis
Dr. Tammy M. Meyers
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Discussion of Management
Dr. Tammy M. Meyers
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Follow-up
Brian C. Zanoni, M.D.
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Follow-up
• CD4 nadir 59 / 6%
• Darunavir – Obtained on a compassionate basis from company– Drug registered with Medicine Counsel
• Regimen changed:– Darunavir 375 mg twice daily– Ritonavir 100 mg twice daily– EFV 300 mg daily
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Follow-up
• 2 weeks later– Developed fever, cough, and new right middle lobe
infiltrate– Diagnosed with pneumonia
• Responded to oral antibiotics
• 8 weeks after change of regimen– Clinically well– Weight: 21.43 Kg (5% - 10%)– CD4: 193 / 5.8%– VL: 150
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