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Case 2 50 year-old man from Hong Kong
Case 2 50 year-old man from Hong Kong
Case 2 50 year-old man from Hong Kong
Case 2 50 year-old man from Hong Kong
Case 2 50 year-old man from Hong Kong
Case 2 50 year-old man from Hong Kong
Case 2 50 year-old man from Hong Kong
Case 2 50 year-old man from Hong Kong
Case 2 50 year-old man from Hong Kong
Case 2 50 year-old man from Hong Kong
Case 2 50 year-old man from Hong Kong
Case 2 50 year-old man from Hong Kong
Case 2 50 year-old man from Hong Kong
Case 2 50 year-old man from Hong Kong
Case 2 50 year-old man from Hong Kong
Case 2 50 year-old man from Hong Kong
Case 2 50 year-old man from Hong Kong
Case 2 50 year-old man from Hong Kong
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Case 2 50 year-old man from Hong Kong

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  • This slide set is useful for General and Acute Medicine, Emergency and Admissions Teams, Gastroenterology, Hepatology ENT and Oncology.
    It concerns a patient who appeared to be at low risk if HIV infection but who had presented with several clinical indicators of HIV infection over a five-year period.
  • GP referral re abnormal LFTs (work up for stress including financial difficulties)
    “low white cell count” (? Portal hypertension).
    November 2007 seen by Hepatology.
    Abnormal LFTs and anaemia.
    One episode rectal bleeding 2006.
  • ENT: “not convinced this is SCC but does look traumatic and inflamed”
  • Oncology correctly ordered an HIV test on diagnosis of lymphoma
  • Resistance to Lamivudine developed due to previous treatment for Hep B
  • ANSWERS:
    (The slides that follow this provide the rationale from the UK national guidelines for HIV testing 2008 and other evidence.)
    If we apply the UK national guidelines for HIV testing 2008 retrospectively:
    YES. Severe psoriasis is a clinical indicator of HIV infection.
    YES. Oral candida is a clinical indicator of HIV infection.
    YES. Unexplained blood dyscrasias and weight loss are both clinical indicators of HIV infection. There were numerous opportunities to have considered HIV testing in this time.
    YES. Both are clinical indicators of HIV infection
    YES. It would have made the subsequent investigations more appropriate and led more quickly to the correct diagnosis
    NO. Any trained healthcare professional can offer and perform an HIV test without in-depth pre-test counselling (see next slide)
  • The conditions outlined in full red are clear clinical indicators for offering an HIV test and represent missed opportunities in this case.
    Those outlined in dotted red are the ones that actually triggered consideration of underlying HIV infection resulting in the test being performed.
  • HIV testing is particularly important in patients with Hep B as the treatment for Hep B uses drugs which are commonly used for HIV infection, so the possibility of drug resistance needs to be considered.
  • A sexual history may not be appropriate in a general medical consultation, but if you are going to take one it is important to be trained to do this in a sensitive way and in a confidential environment
  • Transcript

    • 1. Case 2 • 50 year-old man from Hong Kong • In UK for 35 years • Living in South Coast town • Married 25 years 1
    • 2. Case 2: PMH Mid June 2006 GP referral to Gastroenterology with history of weight loss and anaemia Hb 8.5 End June 2006 OGD: antral gastritis with multiple erosions: biopsies taken: benign Mid July 2006 colonoscopy: normal to caecum with no mucosa abnormalities Planned OPD 6 weeks (no record) 2
    • 3. Case 2: Autumn 2007 GP referral to Hepatology with abnormal LFTs • ALP 196, Bilirubin 21, ALT 100 Hb 11.9, low white cell count Seen by Hepatology • No history of liver disease; no jaundice; no medications; no drug use; no herbal medications or Chinese tea; no alcohol. • In view of ethnicity? Chronic Hepatitis B 3
    • 4. Case 2: Autumn 2007 • HBsAg positive, HBeAg positive, HCV negative • USS normal; declined liver biopsy • Liver screen otherwise normal (no HIV test) • Started lamivudine and adefovir 4
    • 5. Case 2: June/July 2008 GP referral to Oral Surgery: seen end June 2008 • Large healing ulcer left palate • Biopsied beginning July 2008 • Seen with result mid July 2008 • Diffuse large B-cell lymphoma • Referred to Oncology 5
    • 6. Case 2: PMH (cont.) From GP letter of June 2008: • Seen for severe psoriasis in Sept 2003 • Seen for oral candida in May 2006 6
    • 7. Case 2: August 2008 Seen by Oncology beginning August 2008 • HIV test – positive • B-cell lymphoma: – localised disease – No “B” symptoms • R-CHOP commenced as inpatient 7
    • 8. Case 2: August 2008 • HIV: CD4 count 0 (0%) VL 167,505 Resistance test sent Antiretrovirals started mid August 2008 Truvada; Etravirine; Raltegravir; T-20 2 week CD4 1 VL 9404 Resistance test shows drug resistance (M184V) 8
    • 9. Case 2: summary Sept 2003 psoriasis May 2006 oral candida June 2006 anaemia, weight loss OGD: gastritis, colonoscopy: NAD Nov 2007 abnormal LFTs; low WCC chronic hepatitis B July 2008 ulcer on palate: large B-cell lymphoma Aug 2008 HIV diagnosed: CD4 0: VL 167,505 9
    • 10. Q: At which of his healthcare interactions could HIV testing have been performed? 1. When he saw his GP for psoriasis? 2. When he saw his GP for oral candida? 3. When he was seen in Gastroenterology for anaemia/weight loss? 4. When he was found by Hepatology to have low WCC/hepatitis B? 5. When he was seen in ENT for oral surgery? 6. Should he have been referred to GUM to see a trained counsellor before HIV testing? 10
    • 11. Who can test? 11
    • 12. Who to test? 12 Who to test?
    • 13. 13 Who to test?
    • 14. 14 Who to test?
    • 15. Sept 2003 psoriasis May 2006 oral candida June 2006 anaemia, weight loss OGD: gastritis, colonoscopy: NAD Nov 2007 abnormal LFTs; low WCC chronic hepatitis B July 2008 ulcer on palate: large B-cell lymphoma Aug 2008 HIV diagnosed: CD4 0: VL 167,505 15 5 missed opportunities! If current guidelines used, HIV could have been diagnosed up to 5 years earlier
    • 16. Learning Points • Because of his nadir CD4 of 0 he has an increased risk of potential problems despite control of his HIV now • He did not disclose any risk factors when his initial medical history was taken • Because of this the otherwise excellent medical teams looking after him did not think of HIV even when the diagnosis seems obvious with hindsight • A perceived lack of risk should not deter you from offering a test when clinically indicated • Test for HIV before treating for hepatitis B as resistance to lamivudine can compromise future HIV treatment options 16
    • 17. Key messages • Antiretroviral therapy (ART) has transformed treatment of HIV infection • The benefits of early diagnosis of HIV are well recognised - not offering HIV testing represents a missed opportunity • UK guidelines recommend routine HIV testing for patients diagnosed with hepatitis B and lymphoma • HIV screening should become a routine test performed whenever there is a clinical indicator such as oral candida or weight loss • Some patients may not disclose that they have put themselves at risk of HIV infection in the past 17
    • 18. 18 Also contains UK National Guidelines for HIV Testing 2008 from BASHH/BHIVA/BIS Available from: enquiries@medfash.bma.org.uk or 020 7383 6345

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