CASE PRESENTATION

ON

ZIDOVUDINE INDUCED ANAEMIA

CASE PROFILE

A male patient of age 36 years who was HIV positive presents to HIV Department OP with the complaints of breathlessness and giddiness on 22-10-2011.By examining the patient physician advised to admit in the Ward

Breathlessness on exertion since 20 days

Giddiness and fever since 20 days

Headache

Fatigability

Body pains

CHIEF COMPLAINTS

Pallor + + RS :NAD CVS: Tachycardia P/A:Soft,tender in the epigastric

and left hypochondriac region Ht:159.5cms Wt:68 kgs Temp:98F BP:120/70 mm of Hg

DATE OF ADMISSION:22-10-2011DATE OF DISCHARGE:2-11-2011

On Examination

FAMILY HISTORY:

Wife - HIV positive3 childrens:13 years/F-Positive 12years/M-Positive 3 years/M-Negative

SOCIAL HISTORY:

Patient is a driverHe is smoker and alcoholicHe quits alcohol 3 months back

History

PAST MEDICAL AND MEDICATION HISTORY

Patient was diagnosed as HIV positve on 21-09-2007.

ART started on 11-08-2011 with AZT/3TC/NVP

ART changed on 17-10-2011 with DT4/3TC/NVP

Newly diagnosed as hypertensive 5 days back and prescribed withRamipril 1.25mg once daily

ART-Anti retro viral therapy

AZT-Zidovudine

3TC-Lamivudine

NVP-Nevirapine

DT4-Stavudine

CD4-320 cells on 4-09-2007

CD4-318 cells on 10-03-2008

CD4-354 cells on 19-9-2008

CD4-331 cells on 27-04-2009

CD4-329 cells on 04-08-2009

CD4-340 cells on 26-03-2010

CD4-281 cells on 17-02-2011

CD4-213 cells on 04-08-2011

CD4 Count of Patient

Sp Estimated. compound Normal value Observed value

22-1-2011 23-1-2011 24-1-2011Hb 11-16.5g/dl 5.1g/dl 5.18g/dl 6.5g/dl

TC 3500-10000/cum 5100/cum 5100/cum 2700/cum

DC lymphoctes 15-30% 46.2% 46.2% 42.4%

Neutrophils 40-70% 49.2% 49.2% 52.8%

Mid cells 2-10% 4.6% 4.6% 4.8%

PCV 35-50% 12.7% 12.7% 17.6%

Platelets 1-4lac cells/cum 1,79000 179000 130000

MCH 25.4 - 34.6 pg/cell 

28.5 30.1pg/dl 28.4pg/dl

MCHC 31-37 % 38.8% 39.9% 36.99%

RBC 3.80-5.80m/cu 1.2m/cu 1.7m/cu 2.3m/ cu

Total Lymphocytes

15-30% 17% 13% 1.1%

Total Neutrophills 40-80% 13% 1.4% 1.4%

Total Midcells <01% 1% 0.2% 2%

RDWA 11.5-14.0 56.9% 61.6% 64.2%

MPV 7-9 7.7fL 7.6 7.4

PDW <12.0 12.4 11.8 11.8

MCV 7-9 7.3 -

BLOOD

Tests Specimen Est. compound Normal values Observed values

R F

T

RBS 110-180mg/dl 134.4mg/dl

Blood Urea 10-50mg/dl 24.7mg/dl

Sr.creatinine 0.6-1.1mg/dl 0.8mg/dl

Na 135-148mmol/l

139.9mmol/l

K 3.5-5.3mmol/l 4.32mmol/l

Cl 98-107mmol/l 108mmol/l

LDH 150-330U/l 343

L F

T

Bilurubin Total 0.5-1.1mg/dl 0.3mg/dl

Bilurubin Direct Upto 3mg/dl 0.1mg/dl

SGOT 6-38IU/L 25.7IU/L

SGPT 6-38IU/L 43.5IU/L

ALP 36-142mml/ml 76.1mml/ml

Sr.Albumin 3.5-5.0g/dl 4.5g/dl

Total Proteins 6.8-8.3g/dl 7.5g/dl

BLOOD

MP: Negative

Urine albumin-TraceSugar-NillMicro, Pus cells < 2Epithelial cells few <5

Urine Analysis

Vit-B12-549.9pg/ml

Normocytic, normochromic RBCTC-2500/cumSputum AFB-NegativePlatelets are adequate

PERIPHERAL SMEAR

24-10-2011

NORMAL COUNT:

Viral load : <46c/ml <200c/ml

ELISA:

0.089-Non reactive>0.7 –Reactive

DIAGNOSIS:

HTN-Newly diagnosedZidovudine induced anaemia

Blood transfusion done on 22-10-2011 and 2-10-2011

NORMAL COUNT

ELISA

DIAGNOSIS

DIAGNOSIS

ZIDOVuDInE INDUCE

ANAEMIA

The anaemia caused by zidovudine is multifactorial and dose dependent.

It inhibits the proliferation of blood cell progenitor cells in a time and dose dependant fashion.

Zidovidine exhibits cytotoxicity to the myeloid and erythroid precursor in the bone marrow. There by it inhibit the production of RBC.

So haemoglobin monitoring is done particularly in those patients who are taking zidovudine.

Reference: Zidovidine induced anaemia in HIV/AIDS Indian J Med Res 132,october 2010 pp 359-361

.

ZIDOVUDINE INDUCED ANAEMIA

CLINICAL GOALS: Prolongation of life and improvement in quality of life.

VIROLOGICAL GOALS: Greatest possible reduction in the viral load for as long as possible

THERAPEUTIC GOALS: Rational sequencing of drugs in a fashion that achieves clinical, virological and immunological goals while maintaining treatment options, limiting drug toxicity and facilitating adherence

Effective therapy is usually accompanied by a CD4+ cell count increase of 100-200/µL or more within 2 to 4 months.

Reference: Standard treatment guidlines-A manual for medical therapeutics ,Third Edition by sangeetha sharma

GOALS OF “ART” ARE

DRUG DOSE FREQ R.O.A

22 23 24 25

T.Paracetamol 650mg TID PO -

T. Thiamine 75mg Stat PO -

T. Ramipril 1.25mg OD PO - - -

T. Trimethoprim+Sulfamethaxazole

800mg+160mg OD PO - - -

T.Iron and Folic acid

200mg+0.5mg OD PO - - - -

DT3/3TC/NVP 40mg+300mg+200mg

BD PO - - - -

PRESENT MEDICATION

1. Blood pressure was normalized

2. Haemoglobin levels are increased by blood transfusion.

3. Signs and symptoms are relieved

4. Viral load and CD4 count is maintained

THERAPEUTIC OUTCOME

Vitamin B complex OD for 15 days

Co-trimoxazole single strength tablet (80/400) OD for 15 days

Review after 2 weeks

Repeat Hb%Check blood pressure .

DISCHARGE MEDICATIONS

NRTIS are associated with lactic acidosis, lipoatropy and peripheral neuropathy which leads to non-adherence to the long term therapy.

DRUG RELATED PROBLEMS

1) Clinical assessment should be done on each visit of the patient.

2) Routine monitoring of the CD4 count of the patient should be done for every 6 months.

3) Monitoring of complete blood count should be done.

4) Monitoring of short term and long term toxicity of stavudine should be done.

5) Monitoring of the viral load should be done.

MONITORING PARAMETERS

1. Counselling should be done regarding the understanding of ART medications

2. Counsel the patient for better medication adherence.

3. Inform the patient about the adverse effects of ART drugs.

4. Advice the patient to regularly visit the physician.

Life style modifications:

Avoid smoking

PATIENT COUNSELLING

DIETARY RECOMMENDATIONS

Advice the patient to take more green leafy vegetables.

To take enriched bread and cereals and a good source of ascorbic acid at each meal like citrus foods, orange juices, fresh lime improves the absorption of iron.

Advice the patient to take dry foods.

THANKING YOU