Challenging cases in HIV medicine
Dr Ashwini Tayade
Case 1
• 40/male
• HIV positive
• July 2014
-wt loss 10kg in 1 yrs
-low grade fever
- eruptions/rashes over face 3 mths
- - cough
• Diagnosis – 2004 during routine check up
CD4 count - 234(15.2%)
VL - ?
started on ZDV/3TC/NVP
stopped ART after 1 yr
Next follow up
• May 2007
CD4 -227(18%)
VL - 151381
started on Duovir E kit daily
discontinued after taking for 3 years
• Examination
-nodular eruptions over face
-Enlarged lt supraclavicular and lt cervical LN
Labs
• CD 4 – 71 (13%)
• VL – 9,07,490copies/ml
CBC
Hb 4.9
TC 5650
PC 95000
S.Creat-0.9
ESR 140
Peripheral smear – microcytic hypochromic RBCs
Skin leisons
Chest x-ray
Diagnosis
• HIV/AIDS CDC-C, WHO IV ( C/I/V failure)
• OI- Lymphadenitis /lung infiltrate
• Severe anemia/bicytopenia
• Skin leisons
2004 2005 2014
CD4 516(23.8%) 555(23.8%) 119(11%)
Viral load 22,644 1,324,239
• 1.molluscum contagiosum/tb
• 2.TB
• 3.lymphoma
• 4.need biopsy/further test to confirm
• Treatment of OI
?Empirical ATT vs Tissue diagnosis
• ART
- when?
- what regimen?
Plan
• Plan to start PI based regimen
• Empirical ATT
-rifabutin based regimen
• Rifabutin/INH/E/Z
• LN FNAC - AFB smear -negative
Xpert MTB-negative
• ??
Reconsideration of plan
• ??ATT
• Treatment of histoplasma
• ??ART
• ATT stopped
• Itraconazole started
• ART??
- when to start?
- what regimen?
Which ART ? MUTATIONS ?
• 2NRTI+NNRTI
• 2NRTI+PI
• 2NRTI+Integrase inhibitor3TC/AZT/D4T/NVP/EFV
• Tenofovir /emtricitabin/raltegravir
Special Considerations with Regard to
Starting ART
• Started on ART as soon as possible after initiating antifungal therapy (AIII).
• IRIS is reportedly uncommon in HIV-infected patients with histoplasmosis.
• ART should, therefore, not be withheld because of concern for the possible development of IRIS (AIII).
All of the triazole antifungals have the potential for complex, and possibly bidirectional, interactions with certain ARV agents and other anti-infective agents.
Case 2
• 35/male,
• Diagnosed HIV positive 2004
• cd4 -?
• Started on Lamivir-S/EFV-2008 (40/6%)
• Stopped on his own after 2 yrs
• Personal-
owns some property business/partially in politics
married-wife positive
2 kids- negative
gutakha(tobacco),alcohol
MSC
OI- Oral candidiasis
2011
• Chronic diarrhea – work up for OI – negative
• Cd4- 67 (4%)
• Counselled
• Reconfirmed –HIV 1
• Genotype testing was sent -
• Mutations expected?
• New regimen ?
• NRTI- K70E,M184V
• NNRTI- K103N,P225H
TDF/FTC/ATV/RT
V
• Was started on –
• INH prophylaxis
• Took for 1-2 yrs – stopped
• And switched to ayurvedic treatment
2014
• Chronic cough –
• Seen a pulmonologist
• Treated for Pneumocystis and ? NSIP ( no biopsy )(9/5/14- 15/5/14)
• subsequently put on bronchodilators
• And oral steroids intermittently
• Courses of - Clarithromycin, levofloxacin, cotrim
• No relief
• Cd4-??????
• VL- ??????? Stopped ayurvedic as
well
2015(25/3-30/4)
• Persistent cough ,
• Loss of appetite
• Lethargy
• Weight loss
• Difficulty in swallowing
• Exam- oral thrush , no LN ,
• SYST- irritable , disoriented ,no FND, no CN palsy
Labs-
• CBC-10.8/5100/2.63
• LFT- 1/42/22/77
• s.Create- 0.9
• hbsAg,HCV, VDRL – neg
• Chest X ray- normal
• Usg abd – normal
• CD4-4(1%)
• VL – 778050 copies On the day of admission ,he had seizure and
transient loss of consciouness
Possibilities ? What next ?
• 1.TOXOPLASMOSIS
• 2.TB
• 3.CNS LYMPHOMA
• 4.CRYPTOCOCCOMAS
• 5.ASPERGILLUS
• 6.NOCARDIA
• Toxoplasma IgG- >200 IU/ml
• CRAG – Neg
• CSF- sugar- 33.1mg/dl
protein- 41.1 mg/dl
rbs- 101 mg/dl
2-3 cells / lympho
Gm stain
AFB stain –neg
India ink/crag – neg
• Sulfadiazine and pyrimethamine/leucovorin
/antiepileptics
• Persistently irritable
CT chest- patchy infiltrate in post seg left lower lobe
CTA bd- normal
BAL – non contributory
He was started on second line anti-tb
Kanamycin ,etb,pza,,moxiflox,ethionamide,pas, clofazimine
D4T.3TC,EFV,TDF,FTC,ATV,RTV
• 1.NRTI+ PI
• 2.NRTI+PI+INTEGRASE INHIBITOR
• 3.PI+INTEGRASE INHIBITOR
• 4.PI+ NRTI+ INTEGRASE INHIBITOR
Darunavir/ritonavir/raltegravir
/lamivudine/zidovudine
• LFU ,admitted outside seizure
• Antiepileptics escalated
• Cd4 1/2/17-98(7%)
• 24/7/18- 66(7.6%)
• August – irritable
pain in right hand
visual complaints
lethargic
claims to be compliant
Wife
• Diagnosed 2008
• Delivered 2 girl child
• PI based regimen PPTCT - stopped
• Evaluation- asymptomatic
• Cd4-13/4/15- 171(17.4%)
• VL- 53606 copies
• Husband- 2nd line failure
Tdf/ftc/atazanavir,rit
onavir
Compliant
Cd4-753 copies /
VL-<20
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