AWACC 2009AWACC 2009

HIV Case StudyHIV Case StudyDr KR GateDr KR Gate

Dr H SunpathDr H SunpathMcCord’s Hospital Medical DepartmentMcCord’s Hospital Medical Department

01/10/200901/10/2009

Patient SummaryPatient Summary

39yo HIV positive man39yo HIV positive man 2/52 history of productive cough, constitutional 2/52 history of productive cough, constitutional

symptoms and a headachesymptoms and a headache 1/7 Hx of confusion1/7 Hx of confusion No substance abuse but history of herbal medsNo substance abuse but history of herbal meds Stable vitals except for hypothermia mild Stable vitals except for hypothermia mild

tachypnoeatachypnoea Mild respiratory distress with bibasal course Mild respiratory distress with bibasal course

creps, hepatomegally and doughy abdomencreps, hepatomegally and doughy abdomen

Initial Lab ResultsInitial Lab Results

Hb Hb  7.6 7.6 g/Lg/LWBC WBC  6.30 6.30 109/L109/LPLT PLT  135 135 10e9/L10e9/LHCT HCT  22.200 L/L22.200 L/LNormochromic normocytic anaemiaNormochromic normocytic anaemia

Initial Lab ResultsInitial Lab Results

Creat Creat 162 162 Tbili Tbili 50.650.6Urea Urea 1616 ALP ALP 429429Na Na 120120 GGT GGT 217217K+ K+ 4.84.8 ALT ALT 5151Cl- Cl- 9090 AST AST 227227Bicarb Bicarb 1616 ALB ALB 1919

No LDH No LDH availableavailable

Initial Lab ResultsInitial Lab Results

Toxo IgGToxo IgG NegativeNegativeCSF – No abnormalitiesCSF – No abnormalitiesCD4CD4 51 Abs 51 Abs

CD4% CD4% 4.0%4.0%

ESRESR 80mm/hr80mm/hr

CXRCXR

CXRCXR Diffuse bilat interstitial Diffuse bilat interstitial infiltrate, with ?mild infiltrate, with ?mild widening of mediastinum and widening of mediastinum and focal areas of focal areas of consolidation in Lt lower consolidation in Lt lower lobe.lobe.

Initial DiagnosisInitial Diagnosis

RVD with severe immunosuppressionRVD with severe immunosuppressionLRTI with possible underling PTB ?LRTI with possible underling PTB ?

disseminated TBdisseminated TBRenal impairment cause to be establishedRenal impairment cause to be established

IV fluids, IV Augmentin, oral Doxycycline, IV fluids, IV Augmentin, oral Doxycycline, Bactrim prophylaxis and multivitaminBactrim prophylaxis and multivitamin

Day 1Day 1 Pt thought to be clinically septic (tachycardic, hypotensive BP80/50, Pt thought to be clinically septic (tachycardic, hypotensive BP80/50,

spiking temps of 38 degrees C, occasional episodes of hypothermia, spiking temps of 38 degrees C, occasional episodes of hypothermia, tachypnoeic with RR 28, worsening neurological status GCS 13/15tachypnoeic with RR 28, worsening neurological status GCS 13/15

Urea 20, Creat 170, Na 129, K+ 4.0, Cl 104, Bicarb 14Urea 20, Creat 170, Na 129, K+ 4.0, Cl 104, Bicarb 14 Hb 7.0, WCC 1.91 (Neutropenic & Lymphopenic), Plts 25Hb 7.0, WCC 1.91 (Neutropenic & Lymphopenic), Plts 25 Smear showed polychromasia, target cells, anisocytosis, burr cells Smear showed polychromasia, target cells, anisocytosis, burr cells

and confirmed pancytopaeniaand confirmed pancytopaenia INR 1.6INR 1.6 PTT 45 (27-43)PTT 45 (27-43) Coomb’s NegativeCoomb’s Negative Blood cultures drawn, antibiotics changed to Ceftriaxone 1g bd, Blood cultures drawn, antibiotics changed to Ceftriaxone 1g bd,

fluids increased to 6hrlyfluids increased to 6hrly Due to patient’s presenting history, rapid clinical deterioration, CXR Due to patient’s presenting history, rapid clinical deterioration, CXR

possibly suggestive of TB and probably also as a frustrating last possibly suggestive of TB and probably also as a frustrating last ditch effort – TB treatment was commencedditch effort – TB treatment was commenced

Day 2Day 2

Pt had improved slightly – GCS14/15 (attempting to get Pt had improved slightly – GCS14/15 (attempting to get out of bed), BP 90/70, PR 90, still spiking temps with out of bed), BP 90/70, PR 90, still spiking temps with intermittent episodes of temps <35 but trend seemed to intermittent episodes of temps <35 but trend seemed to be responsive to AB’sbe responsive to AB’s

Hb 7.0, WCC 4.0 (still neutro- and lymphopaenia, Hb 7.0, WCC 4.0 (still neutro- and lymphopaenia, eosinophils raised), Plts 134eosinophils raised), Plts 134

INR 2.29INR 2.29 Urea 26, Creat 220, Na 133, K+ 5.2, Cl 108, Bicarb 13Urea 26, Creat 220, Na 133, K+ 5.2, Cl 108, Bicarb 13 Urine output 1.2 litres in last 24hours, urine still very Urine output 1.2 litres in last 24hours, urine still very

concentratedconcentrated Pt sedated and fluids increased to 4hrly NaCl 0.9%Pt sedated and fluids increased to 4hrly NaCl 0.9%

Day 3Day 3 Pt clinically deteriorating, GCS 10/15Pt clinically deteriorating, GCS 10/15 Had received 5 litres of fluid in last 24hrs with good urine outputHad received 5 litres of fluid in last 24hrs with good urine output Temp showing gradual response to treatmentTemp showing gradual response to treatment Urea 26, Creat 240, Na 135, K+ 4.9, Cl 113, Bicarb 11Urea 26, Creat 240, Na 135, K+ 4.9, Cl 113, Bicarb 11 Hb 7.9, WCC 5.4 (Now only lymphopaenic), Plts 112Hb 7.9, WCC 5.4 (Now only lymphopaenic), Plts 112 Tbili 82, Dbili 56.8, ALP 395, GGT 148, ALT 61, AST 207, ALB 12, Tbili 82, Dbili 56.8, ALP 395, GGT 148, ALT 61, AST 207, ALB 12,

LDH 1399LDH 1399 INR 2.31INR 2.31 ABG pH 7.27, HCO3 13.7, BE -11ABG pH 7.27, HCO3 13.7, BE -11 Preliminary blood culture results – No growthPreliminary blood culture results – No growth Transferred to HCUTransferred to HCU

Day 3 HCUDay 3 HCU On arrival in HCU patient found to have PR105, BP100/60, Temp 36, RR 37On arrival in HCU patient found to have PR105, BP100/60, Temp 36, RR 37 CVP = 10, urine output about 50ml/hrCVP = 10, urine output about 50ml/hr Abdomen severely distended with ascites, mild anasarca notedAbdomen severely distended with ascites, mild anasarca noted Assessment made: Assessment made: Severe immune compromiseSevere immune compromise Disseminated TBDisseminated TB Neutropenic sepsis (possible Gram Negative Neutropenic sepsis (possible Gram Negative

sepsis)sepsis) ?DIC (full DIC screen not done) ?TTP ?DIC (full DIC screen not done) ?TTP

(haemolysis, (haemolysis, thrombocytopaenia, ARF, Pyrexia, thrombocytopaenia, ARF, Pyrexia, neurological neurological deterioration)deterioration)

Hypoalbuminaemia,Hypoalbuminaemia, Supportive fluid management and IV AB’s continuedSupportive fluid management and IV AB’s continued

Day 4 & 5Day 4 & 5 Pt deteriorating clinicallyPt deteriorating clinically GCS 5/15 with severe neck stiffnessGCS 5/15 with severe neck stiffness Still very acidotic clinically, anasarca worsening, course creps bilat on Still very acidotic clinically, anasarca worsening, course creps bilat on

auscultation of chestauscultation of chest Hb 7.2, WCC 6.9, Plts 29Hb 7.2, WCC 6.9, Plts 29 Urea 26.6, Creat 229Urea 26.6, Creat 229 LFT’s ISQLFT’s ISQ INR 1.81INR 1.81 ABG pH 7.2, HCO3 13ABG pH 7.2, HCO3 13 LP not repeated due to low plateletsLP not repeated due to low platelets Blood cultures - No growthBlood cultures - No growth Prognosis extremely guarded at this stage and family called in in Prognosis extremely guarded at this stage and family called in in

preparation of “inevitable”preparation of “inevitable” Hydrocortisone started for thrombocytopaenia.Hydrocortisone started for thrombocytopaenia.

Day 6Day 6

Pt looking slightly betterPt looking slightly better GCS improved to 8/15GCS improved to 8/15 Vitals stable, good urine outputVitals stable, good urine output ABG pH ABG pH 7.327.32, HCO3 15, HCO3 15 Hb 6.4Hb 6.4, WCC 6.6, , WCC 6.6, Plts 86Plts 86 LFT’s stable with only Tbili improving to 31 and LDH LFT’s stable with only Tbili improving to 31 and LDH

down to 821down to 821 INR 1.88INR 1.88 Urea 26, Urea 26, Creat 204Creat 204, Bicarb 15, Bicarb 15

Day 7Day 7

GCS 9/15GCS 9/15 Vitals stableVitals stable Still very swollen with abd distension, chest sounding Still very swollen with abd distension, chest sounding

slightly betterslightly better Hb 5.4, WCC 7.59, Plts 41Hb 5.4, WCC 7.59, Plts 41 INR 1.57INR 1.57 Urea 22.3, Creat 182, Bicarb 15Urea 22.3, Creat 182, Bicarb 15 LFT’s ISQLFT’s ISQ Transfused 2U packed cellsTransfused 2U packed cells

Day 8 & 9Day 8 & 9

GCS 12/15 Pt now very restless and GCS 12/15 Pt now very restless and difficult to manage, kept sedateddifficult to manage, kept sedated

Hb 7.2, Plts 49Hb 7.2, Plts 49LFT’s remained unchanged except for Alb LFT’s remained unchanged except for Alb

improved to 16improved to 16 INR 1.5INR 1.5

Day 10Day 10

GCS still 12/15 (pt however sedated)GCS still 12/15 (pt however sedated)Vitals stable Vitals stable Hb 6.7, WCC 8.82, Plts 37Hb 6.7, WCC 8.82, Plts 37Urea 13, Creat 155 Na 155, K+ 2.8 Bicarb Urea 13, Creat 155 Na 155, K+ 2.8 Bicarb

2222Ceftriaxone stopped, oral Slow K startedCeftriaxone stopped, oral Slow K started

Day 11Day 11

Pt ISQ but now spiking temps againPt ISQ but now spiking temps againConcern about nosocomial infection Concern about nosocomial infection

therefore all lines removed and sent for therefore all lines removed and sent for MC&S, blood cultures repeatedMC&S, blood cultures repeated

Augmentin and Flagyl startedAugmentin and Flagyl started

Day 12Day 12

Pt doing very wellPt doing very well Temp responded to AB’s, GCS now at 15/15, patient feeding Temp responded to AB’s, GCS now at 15/15, patient feeding

himself, responding appropriately but still very weakhimself, responding appropriately but still very weak Staph Aureus cultured on urinary catheter sensitive to Staph Aureus cultured on urinary catheter sensitive to

AugmentinAugmentin Hb 5.1, Plts 58 Pt transfused another 2u packed cellsHb 5.1, Plts 58 Pt transfused another 2u packed cells Other blood parameters K+ now at 2.1, Mg 0.5, Phosphate Other blood parameters K+ now at 2.1, Mg 0.5, Phosphate

0.49 – Corrected with IV KCL, Slow Mag and Sandoz 0.49 – Corrected with IV KCL, Slow Mag and Sandoz Phosphate – Probable refeeding syndrome with patient taking Phosphate – Probable refeeding syndrome with patient taking own feeds.own feeds.

ARV therapy initiated due to thrombocytopaenia (Regime 1a)ARV therapy initiated due to thrombocytopaenia (Regime 1a)

Day 13Day 13

Pt convulsed once in evening. Sent for CT scan head – Pt convulsed once in evening. Sent for CT scan head – NADNAD

Still battling to correct electrolytesStill battling to correct electrolytes Urea 3.0, Creat 66, Bicarb 25Urea 3.0, Creat 66, Bicarb 25 Mg 0.38, Corrected Ca 1.68, Phosphate 0.58Mg 0.38, Corrected Ca 1.68, Phosphate 0.58 IV KCL needed again, Mg and phosphate supplements IV KCL needed again, Mg and phosphate supplements

increased, IV Mag Sulph and Ca Gluconate givenincreased, IV Mag Sulph and Ca Gluconate given Electrolyte deficiency probably cause of convulsionElectrolyte deficiency probably cause of convulsion Pt recovered fully from convulsion with above therapy Pt recovered fully from convulsion with above therapy

and CMP and K+ normalized with supplementation over and CMP and K+ normalized with supplementation over next 3 daysnext 3 days

Day 15 - 21Day 15 - 21 Pt continued to do well on ARV’sPt continued to do well on ARV’s Eventually discharged home on day 21Eventually discharged home on day 21 Mobilizing independently, GCS 15/15, no more convulsionsMobilizing independently, GCS 15/15, no more convulsions Hb 9.0, WCC 5.6, Plts 102Hb 9.0, WCC 5.6, Plts 102 Urea 5.1, Creat 66, Na 133, K+4.1, Bicarb 24Urea 5.1, Creat 66, Na 133, K+4.1, Bicarb 24 INR 1.2INR 1.2 CMP – normalCMP – normal Tbili 30, ALP 680, GGT 504, ALT 42, AST 91, ALB 16, LDH 1280Tbili 30, ALP 680, GGT 504, ALT 42, AST 91, ALB 16, LDH 1280 TTO – Bactrim 2tabs dly, Rifafour 4tabs dly, Pyridoxine 25mg dly, TTO – Bactrim 2tabs dly, Rifafour 4tabs dly, Pyridoxine 25mg dly,

Prednisone 10mg dly for 1/12, 3TC 150mg bd, D4T 30mg bd, EFV Prednisone 10mg dly for 1/12, 3TC 150mg bd, D4T 30mg bd, EFV 600mg nocte600mg nocte

5/52 on ARV’s5/52 on ARV’s Pt reports feeling weak, recently started with severe nights and Pt reports feeling weak, recently started with severe nights and

losing weight againlosing weight again Tachycardic with PR @120, BP 100/60, Apyrexial, no resp distressTachycardic with PR @120, BP 100/60, Apyrexial, no resp distress ++Oral candida++Oral candida chest clear, A/E = bilatchest clear, A/E = bilat Abd - Tender epigastrium and LUQ, palpable hepatomegally of 5cm Abd - Tender epigastrium and LUQ, palpable hepatomegally of 5cm

BCMBCM ?palpable mesenteric LN?palpable mesenteric LN Abd US showed abd LN and cavitating abd mass (?LN)Abd US showed abd LN and cavitating abd mass (?LN) Lfts show worsening cholangiopathic/infiltrative picture.Lfts show worsening cholangiopathic/infiltrative picture. Assessment of possible TB IRIS made and patient readmittedAssessment of possible TB IRIS made and patient readmitted

Days 1-7 ReadmissionDays 1-7 Readmission

CT abdomen done which showed hepatic and splenic CT abdomen done which showed hepatic and splenic granulomas, numerous abd LN with some showing granulomas, numerous abd LN with some showing evidence of central necrosis.evidence of central necrosis.

Pt started on IV hydrocortisone and responded very wellPt started on IV hydrocortisone and responded very well Fluconazole started for presumed oesophageal Fluconazole started for presumed oesophageal

candidiasiscandidiasis Abd pain improved, night sweats ceased and patient Abd pain improved, night sweats ceased and patient

started gaining weight again.started gaining weight again. However liver functions continued to deteriorate slowly However liver functions continued to deteriorate slowly

as shown:as shown:

31/7/200931/7/2009 03/08/200903/08/2009

TBiliTBili 1313 11.311.3 ALPALP 12991299 11341134 GGTGGT 938938 811811 ALTALT 147147 238238 ASTAST 134134 218218 TProtTProt 9595 7070 AlbAlb 2222 1717 LDHLDH 505505 600600

Due to infiltrative/cholangiopathic picture slowly starting Due to infiltrative/cholangiopathic picture slowly starting to convert to a hepatocellur damage picture decision to convert to a hepatocellur damage picture decision made to switch patient to a liver friendly regimemade to switch patient to a liver friendly regime

Pt improved clinically, LFT’s remained stable and did not Pt improved clinically, LFT’s remained stable and did not deteriorate furtherdeteriorate further

Pt discharged on 7 readmissionPt discharged on 7 readmission

2/12 on ARV’s2/12 on ARV’s Doing very well. Reports feeling good, gained 10kg of since last Doing very well. Reports feeling good, gained 10kg of since last

discharge.discharge. No constitutional symptoms, good appetite, no abd painNo constitutional symptoms, good appetite, no abd pain Hb 9.8, WCC 7.2, Plts 273, INR 1.1Hb 9.8, WCC 7.2, Plts 273, INR 1.1 Urea 4.5, Creat 61, Na 134, K+ 4.5Urea 4.5, Creat 61, Na 134, K+ 4.5 Tbili 13, ALP 1461, GGT 1324, ALT 83, AST 163, Tprot 83, Alb 23, Tbili 13, ALP 1461, GGT 1324, ALT 83, AST 163, Tprot 83, Alb 23,

LDH800LDH800 Currently on Ethambutol 1.2g dly, Rifampicin 600mg dly, INH Currently on Ethambutol 1.2g dly, Rifampicin 600mg dly, INH

300mg dly, Pyridoxine 25mg dly300mg dly, Pyridoxine 25mg dly 3TC, D4T, EFV, Bactrim (prophylaxis) and Multivites3TC, D4T, EFV, Bactrim (prophylaxis) and Multivites

SummarySummary

39yo man with CD4 of 5139yo man with CD4 of 51 Presented with neutropenic sepsis and signs of Presented with neutropenic sepsis and signs of

disseminated TBdisseminated TB Whilst in hospital patient developed signs in keeping with Whilst in hospital patient developed signs in keeping with

TTP (Fever, neurological deterioration, TTP (Fever, neurological deterioration, thrombocytopaenia and haemolysis, acute renal failure) thrombocytopaenia and haemolysis, acute renal failure) but unfortunately not confirmed ?was it all DICbut unfortunately not confirmed ?was it all DIC

The above was treated with IV Ceftriaxone, TB The above was treated with IV Ceftriaxone, TB treatment, supportive fluid therapy and steroids.treatment, supportive fluid therapy and steroids.

Initiated on ARV’s on Day 12 of hospital stay.Initiated on ARV’s on Day 12 of hospital stay.

Summary cont.

Eventually discharged on TB treatment, ARV’s Eventually discharged on TB treatment, ARV’s and low dose steroidsand low dose steroids

Patient then readmitted with Abd TB IRIS and Patient then readmitted with Abd TB IRIS and concern about a coexisting drug induced concern about a coexisting drug induced hepatitishepatitis

ARV’s continued, IV steroids started and patient ARV’s continued, IV steroids started and patient switched to a liver friendly TB drug regimeswitched to a liver friendly TB drug regime

Patient currently continues to recover nicely with Patient currently continues to recover nicely with gradually improving haematological, renal, gradually improving haematological, renal, electrolyte and hepatic functions.electrolyte and hepatic functions.

In ClosingIn Closing

We presented this case because of this relatively We presented this case because of this relatively common scenario of a patient with HIV presenting common scenario of a patient with HIV presenting critically ill and, in this patient’s case, spending a critically ill and, in this patient’s case, spending a significant period of time in an ICU settingsignificant period of time in an ICU setting

Questions:Questions: Differential diagnosis of thrombocytopaenia in the setting of Differential diagnosis of thrombocytopaenia in the setting of

HIV?HIV? What does the literature show concerning the place of the What does the literature show concerning the place of the

initiation of HAART in critically ill patients?initiation of HAART in critically ill patients?

Should we have waited before initiating ARV’s, did this Should we have waited before initiating ARV’s, did this contribute to his IRIS or did it hasten his recovery?contribute to his IRIS or did it hasten his recovery?

IRIS TB in patients on TB treatment, ARV’s and steroids?IRIS TB in patients on TB treatment, ARV’s and steroids?