Aids case


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Aids case

  1. 1. HIV -AIDS with CRYPTOCOCCAL MENINGITIS Doney Joseph PharmD Intern
  2. 2.  AIDS (Acquired immune deficiency syndrome) is a disease caused by a virus called HIV (Human Immunodeficiency Virus).  The illness alters the immune system, making people much more vulnerable to infections and diseases.  India has a population of 1.2 billion people, around half of whom are adults in the sexually active age group  The first AIDS case in India was detected in 1986 and since then HIV infection has been reported in all states and union territories..
  3. 3.  HIV is the virus which attacks the T-cells in the immune system. AIDS is the syndrome which appears in advanced stages of HIV infection. HIV is a virus. AIDS is a medical condition
  4. 4. Stages of HIV Stage 1 (Asymptomatic)  Asymptomatic  Persistent generalized lymphadinopathy Stage 2 (Mild)  Unexplained moderate weight loss (<10%)  Recurrent respiratory tract infections  Herpes zoster  Recurrent oral ulceration  Papular pruritic eruptions  Fungal nail infections Staging of HIV is based on OIs: •STAGE 1 •STAGE 2 •Stage 3 •Stage 4
  5. 5. Stages of HIV Advanced:  Unexplained severe weight loss (>10%)  Unexplained chronic diarrhea for longer than one month  Unexplained persistent fever (above 37.5oC intermittent or constant for longer than one month)  Persistent oral candidiasis  Pulmonary tuberculosis  Severe bacterial infections,  bacteraemia)  Unexplained anaemia (<8 g/dl), neutropenia (<0.5 X 109/litre) and or chronic thrombocytopenia(<50 X 109/litre3) •Stage 1 •Stage 2 •STAGE 3 •Stage 4
  6. 6. Stages of HIV Severe:  HIV wasting syndrome  Pneumocystis pneumonia  Recurrent severe bacterial pneumonia  Chronic herpes simplex infection Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs)  Extrapulmonary tuberculosis  Cytomegalo virus infection  Toxoplasmosis  HIV encephalopathy  Extrapulmonary cryptococcosis including meningitis  Disseminated non-tuberculous mycobacteria infection •Stage 1 •Stage 2 •Stage 3 •STAGE 4
  7. 7. First line ART regimens for adults, adolescents, pregnant and breastfeeding women and children (June-2013 WHO CONSOLIDATED guidelines) FIRST LINE ART PREFERRED FRIST LINE REGIMENS ALTERNATIVE FIRST LINE REGIMENS Adults (Including pregnant women and breastfeeding women and adults with TB and HBV co infection) TDF+3TC+EFZ ZDV + 3TC + EFV ZDV + 3TC + NVP TDF + 3TC + NVP Adolescents (10 to 19 years) ≥35 kg ZDV + 3TC + EFV ZDV + 3TC + NVP TDF + 3TC + NVP ABC + 3TC + EFV (or NVP) Children 3 years to less than 10 years and adolescents <35 kg ABC + 3TC + EFZ ABC + 3TC + NVP ZDV + 3TC + EFZ/NVP TDF + 3TC + NVP/EFZ Children <3 years ABC or ZDV + 3TC + LPV/r ABC + 3TC + NVP ZDV + 3TC + NVP
  8. 8. Rationale and supporting evidence (The move to TDF+3TC+EFZ as preferred first line option)  A systematic review comparing 6 regimens showed that a once daily combination of TDF+3TC+EFZ is less frequently associated with severe adverse events and has a better virological and treatment response compared with other once/twice regimens. People receiving NVP are twice likely to discontinue treatment bcoz of ADRs compared to EFZ (
  9. 9. When to start ART in Adults and adolescents (June-2013 WHO CONSOLIDATED guidelines)  ART should be initiated in all individuals with Severe and advanced HIV clinical disease(WHO clinical stages 3 or 4) and individuals with cd4 count less than on equal to 350cells/mm3.  ART should be initiated in all individuals with HIV and CD4 count grater than 350cells/mm3 and less than or equal to 500cells/mm3 regardless of WHO clinical staging.  ART should be initiated regardless of CD4 and Clinical staging in following conditions: 1. Individuals with HIV and active TB 2. HIV and HBV infection with evidence of chronic liver disease. 3. Pregnant and breastfeeding women with HIV
  10. 10. Cryptococcal Meningitis?  Cryptococcal meningitis is one of the most important opportunistic infections and a major contributor to high mortality before and after ART is initiated.  The infection is not contagious. General symptoms includes: Headache Fever Neck pain Nausea and vomiting Sensitivity to light Altered mental status (Includes confusion to coma)
  11. 11. Age:45 years Unit: AKH Sex: Male Weight:48 Kg
  12. 12. PMHx  Patient is a k/c/o HIV since 5 years and on ART since 1 year (TDF+3TC+EFZ) FHx:  2 children –NR, wife –expired (7 yrs ago)
  13. 13. Reasons for admission:  C/o fever, vomiting, headache since 1 week  Difficulty in hearing and confusion (4 days)
  14. 14. Day 1 BP : 130/80mm Hg Pulse: 82 bpm Temp:101f o/e: CVS: S1 S2 + RS:B/L NVBS + CNS: Conscious disoriented P/A:soft, non tender Adv: Hb, TC, DC, Platelet count, ESR, S/E, IgG antibodies, CSF analysis, India ink stain test, CD4 cells
  15. 15. Drug Dose Route Frequency IVF DNS WITH MULTIVITAMIN dex:5g+Nacl:0.9g+MV I:10ml IV stat T.Paracetamol 650mg PO SoS Inj.Ondansetron 2mg IV SoS
  16. 16. Day 2 BP- 130/80mm Hg Pulse- 80bpm Temp: 100f o/e: vomiting decreased CVS: S1 S2 + RS:B/L NVBS+ P/A:soft, non tender CNS: conscious disoriented Adv: CST
  17. 17. Lab Parameters Hematology HB:12g% WBC: 9000cells/mm3 N: 70% L: 23% M: 04% E: 03% PLT: 2.07 lakhscells/cumm ESR: 80mm/hr CSF analysis: Glucose - 40mg/dl Protein - 200mg/dl WBC – 300 cells/μl CD4 Count: 265 cells Serum Electrolytes Na : 134 mmol/L K : 3.6 mmol/L Cl : 101 mmol/L
  18. 18. Day 3 BP- 120/80mm Hg Pulse- 82bpm o/e: Afebrile CVS: S1 S2 + RS:B/L NVBS + P/A:soft ,non tender CNS: conscious disoriented Lab Report: AFB – Negative India ink stain – Positive IgG antibodies – Not detected
  19. 19. Drug Dose Route Frequency Fluconazole 400 mg PO 1-0-1 Amphotericin B 50 mg IV 1-0-0
  20. 20. Day 4,5 BP- 120/80mm Hg Pulse- 82bpm o/e: CVS: S1 S2 heard RS:B/L NVBS Heard P/A:soft, non tender CNS: conscious disoriented ADV:CST
  21. 21. Day 6 BP- 120/80mm Hg Pulse- 80bpm o/e: CVS: S1 S2 heard RS:B/L NVBS Heard P/A:soft ,non tender CNS: conscious disorientation decreased (able to hear without difficulty) ADV: Continue
  22. 22. Pharmaceutical care plan
  23. 23. Subjective evidence Objective evidence Headache CSF analysis Vomiting India ink stain Fever
  24. 24. Provisional Diagnosis HIV with cryptococcal meningitis
  25. 25. Goals of the treatment  Clinical goals: Prolongation of life and improvement in quality of life  Virologic goals: Greatest possible reduction in viral load as long as possible  Therapeutic goals:limiting drug toxicity and facilitating adherence.
  26. 26. Treatment Options HIV  Lamivudine+Tenofovir+Efavirenz Fever-Paracetamol Vomiting-Ondansetron
  27. 27. Cryptococcal meningitis  Administer Amphotericin-B at 0.7-1mg/kg/day for 2 weeks with/without 2 weeks of Flucytosine at 100mg/kg/day in 4 divided doses, followed by fluconazole at 400mg/day for minimum of 8-10 weeks.  Alternate initial therapy includes lipid formulation of Amphotericin-B in doses of 4- 6mg/kg/day for 3 weeks with fluconazole 400mg BID.  {Treat Cryptococcal meningitis first, start ART when patient is stabilized or OI treatment is completed}.
  28. 28. Goals Achieved  Vomiting decreased by day 2  Fever decreased by day 3  Reduction in Hearing difficulty by day 6
  29. 29. Monitoring Parameters Disease:  Viral load (every 6 months after ART and every 12 months thereafter) {June-2013 WHO guidelines}  CD4 count if viral load not available. Drugs:  Renal function tests (TDF,3TC, Fluconazole, Amphotericin-B)  Serum transaminases, cholesterol (EFZ,)  Liver function tests (Fluconazole, Amphotericin-B)  Potassium levels (Fluconazole, Amphotericin-B)
  30. 30. Problems Identified Nill
  31. 31. Patient counseling  About disease This particular virus can only infect human beings HIV weakens immune system by destroying important cells that fight disease and infection. A "deficient" immune system can't protect the person.
  32. 32. About drugs: Importance of medication adherence.  Mobile phone text messages could be considered as a reminder tool for promoting adherence to ART as part of a package of adherence interventions (June 2013 WHO guidelines)  If missed doses (even 2 doses in a month) DRUG RESISTANCE can develop. This is bad for the patient (These drugs will stop working.)  Drugs must be taken twice daily, and miss no doses.  If forget a dose, do not take a double dose.  Drugs MUST NOT be shared with family and friends.
  33. 33. Life style modification:
  34. 34.  THANK..UUUUU