H I V/ T B CO INFECTION A CASE PRESENTATION

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this case presentation demonstrates the need for systemic review during history taking in patients with HIV. more so in patients coinfected with TB

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H I V/ T B CO INFECTION A CASE PRESENTATION

  1. 1. HIV/TB Co infection: A case presentation Dr Farouk Muhammad Dayyab ( [email_address] ) Government House Clinic Jalingo 18th February, 2009
  2. 2. Synopsis <ul><li>History </li></ul><ul><li>Examination </li></ul><ul><li>Assessment </li></ul><ul><li>Management plan </li></ul><ul><li>Investigation results </li></ul><ul><li>Analysis of the History </li></ul><ul><li>Analysis of Examination findings </li></ul><ul><li>Comments on the management plan </li></ul><ul><li>Conclusion </li></ul><ul><li>Reference </li></ul>
  3. 3. History <ul><li>I am presenting Mr M.K. Unit No 18210, a 32yr old male muslim applicant from Magami quarters who presented on the 24th september 2007 at this clinic with 1 week history of fever, cough and diarrhoea. These symptoms have been on and off prior to that episode. </li></ul><ul><li>His wife died of chronic illness. </li></ul>
  4. 4. Examination <ul><li>A chronically ill looking young man wasted afebrile, anicteric, acyanosed not dehydrated and no pedal edema. No peripheral lymphadenopathy. </li></ul>
  5. 5. Assessment <ul><li>PTB R/O RVI </li></ul>
  6. 6. Management Plan <ul><li>Pretest councelling for RVS </li></ul><ul><li>CD4 cell count, E/U/CR, LFT </li></ul><ul><li>Sputum AFB X 3, CXR </li></ul><ul><li>Tabs Ciprofloxacin, Metronidazole and Fansidar. </li></ul>
  7. 7. Investigation results <ul><li>Seropositive </li></ul><ul><li>AFB X 3 ( - ve ) </li></ul><ul><li>CXR- Suggestive </li></ul><ul><li>CD4 count – 60 </li></ul><ul><li>PCV – 34% </li></ul><ul><li>LFT – normal </li></ul><ul><li>U/E/Cr – normal </li></ul>
  8. 8. Plan <ul><li>Commence on DOTS and HAART </li></ul><ul><li>To Substitute Nevirapine with Efavirenz </li></ul>
  9. 9. Analysis of History Missing Aspects <ul><li>Systemic review </li></ul><ul><li>Past Medical History </li></ul><ul><li>Drug History </li></ul><ul><li>*Family and Social History </li></ul>
  10. 10. Why Systemic Review in this HIV/TB Patient? <ul><li>HIV is a Multi-Systemic Disease </li></ul><ul><li>HIV/TB Patients are more likely to have extra-pulmonary Tuberculosis .....Extrapulmonary TB occurs in 70% of HIV related TB cases when CD4 count is less than 100.(Francis J Curry National TB centre USA) </li></ul>
  11. 11. Why Systemic Review in this HIV/TB Patient? the chest <ul><li>History of cough, hemoptysis, dyspnoea, chest pain, stridor and hoarseness of the voice </li></ul><ul><li>BECAUSE: </li></ul><ul><li>PTB </li></ul><ul><li>RVI: PCP, CMV Pneumonia, Fungal chest infections(Histoplasmosis, aspergillosis, blastomycosis), Kaposis sarcoma of the lungs, lymphoid interstitial pneumonitis, lymphomas </li></ul>
  12. 12. Why Systemic Review in this HIV/TB Patient? the git <ul><li>History of abdominal pain, nausea, vomitting, loss of appetite, weight loss, difficulty swallowing, haematemesis, abdominal distention, constipation, diarrhoea, anorexia, regurgitation, jaundice, haematokisea, melaena, anal protrusion, hiccups, steatorrhoea, pruritus. </li></ul><ul><li>BECAUSE: </li></ul><ul><li>TB: Abdominal TB(TB Ileitis, peritonitis and adenitis) </li></ul><ul><li>RVI:Ascending cholangitis, chronic diarrhoea from opportunistic infections(Cryptosporidium, isospora belli, microsporidium),HIV enteropathy, giardia lamblia,E. Histolitica, E. Fragilis, Shigella, Adeno virus and rota virus, Anorectal ca., fistula in ano, anal fissures. </li></ul>
  13. 13. Why Systemic Review in this HIV/TB Patient? the cvs <ul><li>History of dyspnoea, PND, orthopnoea, cough,hemoptysis, fatique, syncopal attack, intermittent claudication, pedal edema, symptoms of pericarditis(pain behind the left sternal border aggravated by sneezing, swallowing and deep breathing) </li></ul><ul><li>BECAUSE: </li></ul><ul><li>TB: TB pericarditis </li></ul><ul><li>RVI: HIV cardiomyopathy, vasculitis. </li></ul>
  14. 14. Why Systemic Review in this HIV/TB Patient? the cns <ul><li>History of headache, tremors, nervousness, excitability, fainting attacks, pits, irrational behaviour, paralysis(hemi/para paresis or phlegia), sensory or hearing disturbances, change in vision, smell or taste. </li></ul><ul><li>BECAUSE: </li></ul><ul><li>TB: TB Meningitis </li></ul><ul><li>RVI: Meningoenchephalitis, cranial nerve palsies, peripheral neuropathy, tubercular enchephalitis, cryptococcal meningitis, AIDS-related dementia, progressive multifocal leukoenchephalopathy, seizure disorders, hemiphlegias and paraphlegias. </li></ul>
  15. 15. Why Systemic Review in this HIV/TB Patient? the gut <ul><li>History of loin pain, suprapubic pain, frequency, urgency or hesitency, dysuria, oliguria, anuria, polyuria, hematuria, urethral discharge, facial swelling. </li></ul><ul><li>BECAUSE: </li></ul><ul><li>TB: Urogenital TB(urethritis, cystitis, etc) </li></ul><ul><li>RVI: HIV nephropathy, Penile ca., Genital wart, worsening of STI especially syphyllis. </li></ul>
  16. 16. Why Systemic Review in this HIV/TB Patient? the mss <ul><li>History of muscle, joint, or bone pain, swelling or limitation of movement. </li></ul><ul><li>BECAUSE: </li></ul><ul><li>1. TB: Skeletal Tuberculosis, Potts disease- Tb spondylitis>Gibbus(vertebral collapse) </li></ul>
  17. 17. Why Past Medical History in this HIV/TB Patient? <ul><li>BECAUSE: </li></ul><ul><li>Past history of hospital admissions and blood transfusion. </li></ul><ul><li>Any history of DM which predisposes to TB </li></ul>
  18. 18. Why Drug History in this HIV/TB Patient? <ul><li>BECAUSE: </li></ul><ul><li>Long term steroid use predisposed to TB </li></ul><ul><li>To check interactions with HIV/TB drugs to be given. </li></ul><ul><li>Past history of use of anti TB drugs </li></ul>
  19. 19. Why Family and Social History in this HIV/TB Patient? <ul><li>BECAUSE: </li></ul><ul><li>Sexual history: promiscuity, STIs </li></ul><ul><li>Marital History: Previous and Present marriages </li></ul><ul><li>Alcohol consumption predisposes to TB </li></ul>
  20. 20. Analysis of Examination Findings <ul><li>?? Findings on chest examination not recorded despite chest symptoms. </li></ul><ul><li>Looking for dyspnoea(Normal:14-16cpm), signs of consolidation(diminished chest expansion,increased tactile fremitus, bronchial breathsounds, crepitations, increased vocal resonance, pleural rub) </li></ul><ul><li>Other systems should be examined based on presence of symptoms in them during history taking. </li></ul>
  21. 21. Comments on the Management Plan: the negative sputum AFB in this HIV/TB Patient <ul><li>Sputum AFB detects 60% of all new TB infections and as few as 20% to 35% in HIV/TB infections. Therefore sputum negativity does not exclude the presence of disease( HIV/TB coinfection: Basic Facts 2007) </li></ul><ul><li>Newer tests include: Sputum inoculation, PCR, Broncho alveolar lavage, Blood medium inoculation, Determination of serum Ag and Ab (Pubmed: Probl Tuberk Bolezn 2007(11):225 ) </li></ul>
  22. 22. Comments on the Management Plan: the CXR <ul><li>The details of the chest XR findings in this patient are not recorded in the case notes but were reported as suggestive of PTB </li></ul><ul><li>CXR findings are CD4 lymphocyte count dependent </li></ul>
  23. 23. Comments on the Management Plan: the CXR <ul><li>Early HIV disease CD4>500 cell/ul: Typical PTB presentation: Upper lobe infilterates, cavitory changes </li></ul><ul><li>Low CD4 count: Lower lobe infilterates, intrathoracic adenopathy, widespread reticulonodular lesions affecting all zones </li></ul><ul><li>HIV infected patients with TB may have a normal chest radiograph.( Francis J Curry National TB centre USA ) </li></ul>
  24. 24. Comments on the Management Plan: the LFT, U/E/Cr were within normal limits in this HIV/TB patient <ul><li>Why LFT, U/E/Cr? </li></ul><ul><li>Metabolism of drugs by the liver </li></ul><ul><li>Excretion of drugs by the kidney </li></ul><ul><li>Both HIV and TB can compromise liver and kidney function </li></ul><ul><li>To know the baseline to monitor drug toxicity. </li></ul>
  25. 25. Comments on the Management Plan: Use of Ciprofloxacin in this Patient <ul><li>Flouroquinolone use delays TB diagnosis in pneumonia patients.( infectious-diseases.jwatch.org ) </li></ul><ul><li>19% of patients thought to have community acquired pneumonia turn out to have TB.( Kenyan Study ) </li></ul><ul><li>Use of moxifloxacin alone even for as short as 7 days leads to emergence of resistance to an important 2nd line agent that reduces the duration of treatment of TB to 4 months when used with other antiTB drugs( Pubmed.org ) </li></ul>
  26. 26. Comments on the Management Plan: Use of Fansidar in this patient. <ul><li>Monotherapy for malaria is no longer recommended by WHO and the Federal Ministry of Health.( Training manual for management of malaria in Nigeria ) </li></ul>
  27. 27. Comments on the Management Plan: Antihelminths not given to this HIV/TB patient <ul><li>Eradication of helminthic infection decreases HIV plasma viral load in dually infected people in a study conducted in Addis Ababa . ( NLM Gateway : A service of the U.S. National Institutes of Health ) </li></ul>
  28. 28. Comments on the Management Plan: Patient was commenced on DOTS and HAART substituting Nevirapine with Efavirenz <ul><li>According to the 2006 WHO recommendations for individuals with HIV/TB coinfection , wether to start DOTS or HAART is based on the CD4 cell count. </li></ul><ul><li>4 Categories: </li></ul><ul><li>CD4<200cells/ul </li></ul><ul><li>CD4 200 – 350 cells/ul </li></ul><ul><li>CD4>350 cells/ul </li></ul><ul><li>CD4 not available. </li></ul>
  29. 29. Comments on the Management Plan: Patient was commenced on DOTS and HAART substituting Nevirapine with Efavirenz <ul><li>CD4<200cells/ul </li></ul><ul><li>Start TB treatment. Start ART as soon as TB treatment is tolerated.(between 2 weeks and 2 months) </li></ul><ul><li>EFV regimen is used. EFV is contraindicated in pregnant women or women of child bearing potential without effective contraception. </li></ul>
  30. 30. Comments on the Management Plan: Patient was commenced on DOTS and HAART substituting Nevirapine with Efavirenz <ul><li>CD4 between 200 – 350 cells/ul </li></ul><ul><li>Start TB treatment for the 2 month intensive phase then commence on ART </li></ul><ul><li>If patient is severely compromised start the ART earlier. </li></ul>
  31. 31. Comments on the Management Plan: Patient was commenced on DOTS and HAART substituting Nevirapine with Efavirenz <ul><li>CD4>350 cells/ul </li></ul><ul><li>1. Start TB treatment, Defer ART. </li></ul>
  32. 32. Comments on the Management Plan: Patient was commenced on DOTS and HAART substituting Nevirapine with Efavirenz <ul><li>CD4 not available : start TB treatment, consider ART.( the internet journal of pulmonary medicine. www.ispub.com ) </li></ul>
  33. 33. Conclusion <ul><li>HIV/TB co infection will continue to be challenging to both health care providers researchers and patients. </li></ul>
  34. 34. Selected references <ul><li>Davidsons principles and practice of medicine 19th edition </li></ul><ul><li>Hutchisons clinical methods 21st edition </li></ul><ul><li>Training manual for management of malaria in nigeria </li></ul><ul><li>Oxford handbook of clinical medicine </li></ul><ul><li>Francis J Curry National TB centre USA www.nationaltbcentre.edu </li></ul><ul><li>HIV/TB coinfection Basic Facts 2007 </li></ul><ul><li>Pubmed: probl Tuberk Bolezn 2007(11):225 </li></ul><ul><li>The internet journal of pulmonary medicine. www.ispub.com </li></ul><ul><li>NLM Gateway : A service of the U.S. National Institutes of Health </li></ul>
  35. 35. Thankyou for listening.

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