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Case 12 Respiratory Medicine, Dermatology

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Case 12 Respiratory Medicine, Dermatology
Case 12
42 year-old female
From South Asia
In UK 8 years
Living in London
Case 12: Feb 2008
Seen in a London ED and admitted to
hospital with:
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Night sweats
Weight loss (4kg)
Intermittent shoulder pain
Lesions on legs
Subsequent rash on face (burning), legs,
forearms and trunk (mildly itchy)
Case 12: inpatient
• 3-night hospital admission - treated with
‘antibiotics’. Discharged.
• Diagnosed with erythema nodosum and chicken
pox on clinical grounds
• No investigations for TB or HIV
But referred to Respiratory Medicine - ?
Case 12: March 2008
Seen in Respiratory OPD
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PUO queried
TB Elispot positive
Chest X-ray clear
ESR and CRP elevated
Abnormal liver function tests (ALP 121,ALT 198)
Hepatitis B serology ‘previous infection’
LATENT TB DIAGNOSED
Referred to Dermatology for rashes on face
and body
Case 12: April 2008
Seen in Dermatology OPD
• Face - fixed erythema + papules/pustules –
rosacea clinically
• Legs - indurated nodular lesions – erythema
nodosum clinically
• Non-specific eczematous eruption on trunk,
forearms
• Nodular indurated lesions on hands
Case 12: April 2008
Differential Diagnosis:
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Cutaneous tuberculid
Lupus erythematosus
Sarcoidosis
Rosacea (face)
HIV
Case 12: April 2008
Investigations:
• Skin biopsies
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Non specific perivascular inflammation
Fungal stains negative
IMF negative
Fungal/AFB/bacterial cultures- negative
Elevated IgA & IgG
Autoimmune profile negative
HIV antibody positive
CD4 198; VL 22,738
Case 12: summary
2000
Registered with GP
Feb 2008
General medical admission
March 2008 Seen in Respiratory OPD – PUO queried,
previous Hep B identified, latent TB diagnosed
April 2008
Seen in Dermatology OPD; cryptic presentation
HIV diagnosed: CD4 198: VL 22,738
Q: At which of her healthcare interactions
could HIV testing have been performed?
1.
When she first registered with her GP?
2.
When she presented to the ED with weight loss and
was admitted?
3.
When she presented to Respirology OPD with
suspected PUO, previous Hep B was identified and
latent TB was diagnosed?
4.
Should she have been referred to GUM to see a
trained counsellor before HIV testing?
Who can test?
Who can test?
Who to test?
Who to test?
Rates of HIV-infected persons accessing
HIV care by area of residence, 2007
13
Source: Health Protection Agency, www.hpa.org.uk
Who to test?
Who to test?
3 missed opportunities!
If current guidelines used, HIV could have been
diagnosed up to 8 years earlier
2000
Registered with GP
Feb 2008
General medical admission, weight loss
March 2008 Seen in Respiratory OPD - PUO queried,
previous Hep B identified, latent TB diagnosed
April 2008
Seen in Dermatology OPD; cryptic presentation
HIV diagnosed: CD4 198; VL 22,738
Learning Points
• This patient came from a country of low HIV prevalence
and was probably not believed to be at risk of HIV
infection
• Because of this the otherwise excellent medical teams
looking after her presumably did not think of HIV even
though the diagnosis seems obvious with hindsight
• However, the suspected PUO and Hepatitis B and TB
diagnoses were a red flag for possible HIV infection
• A perceived lack of risk should not deter you from
offering a test when clinically indicated
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 screening for HIV in adult
populations where undiagnosed prevalence is >1/1000 as
it has been shown to be cost-effective
• HIV screening should be a routine test on presentation of
PUO or weight loss of otherwise unknown cause
• HIV screening should be routine in services for patients
diagnosed with Hepatitis B and TB
Also contains
UK National Guidelines for HIV
Testing 2008
from BASHH/BHIVA/BIS
Available from:
[email protected]
or 020 7383 6345
19
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