clinicopathologic conference advanced update in hiv medicine and clinical research october 1, 2009
DESCRIPTION
Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 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. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 1, 2009](https://reader036.vdocuments.site/reader036/viewer/2022081603/56815a87550346895dc7f8e2/html5/thumbnails/1.jpg)
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
![Page 2: Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 1, 2009](https://reader036.vdocuments.site/reader036/viewer/2022081603/56815a87550346895dc7f8e2/html5/thumbnails/2.jpg)
“A 7-year-old boy with elevated HIV ribonucleic acid levels despite
antiretroviral medications”
Presentation of Case
Brian C. Zanoni, M.D.
![Page 3: Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 1, 2009](https://reader036.vdocuments.site/reader036/viewer/2022081603/56815a87550346895dc7f8e2/html5/thumbnails/3.jpg)
History of Present Illness
• 7 year old HIV positive child on ART transferred care to Sinikithemba Clinic
![Page 4: Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 1, 2009](https://reader036.vdocuments.site/reader036/viewer/2022081603/56815a87550346895dc7f8e2/html5/thumbnails/4.jpg)
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
![Page 5: Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 1, 2009](https://reader036.vdocuments.site/reader036/viewer/2022081603/56815a87550346895dc7f8e2/html5/thumbnails/5.jpg)
History of Present Illness
• At age 3 hospitalized for pneumonia– Clinically diagnosed with pulmonary TB– Completed 6 months of RIF, INH, PZA
![Page 6: Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 1, 2009](https://reader036.vdocuments.site/reader036/viewer/2022081603/56815a87550346895dc7f8e2/html5/thumbnails/6.jpg)
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
![Page 7: Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 1, 2009](https://reader036.vdocuments.site/reader036/viewer/2022081603/56815a87550346895dc7f8e2/html5/thumbnails/7.jpg)
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
![Page 8: Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 1, 2009](https://reader036.vdocuments.site/reader036/viewer/2022081603/56815a87550346895dc7f8e2/html5/thumbnails/8.jpg)
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
![Page 9: Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 1, 2009](https://reader036.vdocuments.site/reader036/viewer/2022081603/56815a87550346895dc7f8e2/html5/thumbnails/9.jpg)
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%)
![Page 10: Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 1, 2009](https://reader036.vdocuments.site/reader036/viewer/2022081603/56815a87550346895dc7f8e2/html5/thumbnails/10.jpg)
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
![Page 11: Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 1, 2009](https://reader036.vdocuments.site/reader036/viewer/2022081603/56815a87550346895dc7f8e2/html5/thumbnails/11.jpg)
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
![Page 12: Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 1, 2009](https://reader036.vdocuments.site/reader036/viewer/2022081603/56815a87550346895dc7f8e2/html5/thumbnails/12.jpg)
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
![Page 13: Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 1, 2009](https://reader036.vdocuments.site/reader036/viewer/2022081603/56815a87550346895dc7f8e2/html5/thumbnails/13.jpg)
Lab Results
• 18 Months on ART– CD4: 146 / 6.1 %
– VL: 4300– Hb: 10.6 MCV 96– LFTs: Normal
![Page 14: Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 1, 2009](https://reader036.vdocuments.site/reader036/viewer/2022081603/56815a87550346895dc7f8e2/html5/thumbnails/14.jpg)
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
![Page 15: Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 1, 2009](https://reader036.vdocuments.site/reader036/viewer/2022081603/56815a87550346895dc7f8e2/html5/thumbnails/15.jpg)
Differential Diagnosis
Dr. Tammy M. Meyers
![Page 16: Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 1, 2009](https://reader036.vdocuments.site/reader036/viewer/2022081603/56815a87550346895dc7f8e2/html5/thumbnails/16.jpg)
Discussion of Management
Dr. Tammy M. Meyers
![Page 17: Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 1, 2009](https://reader036.vdocuments.site/reader036/viewer/2022081603/56815a87550346895dc7f8e2/html5/thumbnails/17.jpg)
Follow-up
Brian C. Zanoni, M.D.
![Page 18: Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 1, 2009](https://reader036.vdocuments.site/reader036/viewer/2022081603/56815a87550346895dc7f8e2/html5/thumbnails/18.jpg)
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
![Page 19: Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 1, 2009](https://reader036.vdocuments.site/reader036/viewer/2022081603/56815a87550346895dc7f8e2/html5/thumbnails/19.jpg)
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
![Page 20: Clinicopathologic Conference Advanced Update in HIV Medicine and Clinical Research October 1, 2009](https://reader036.vdocuments.site/reader036/viewer/2022081603/56815a87550346895dc7f8e2/html5/thumbnails/20.jpg)