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Case 13 General and Emergency Medicine

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Case 13 General and Emergency Medicine
Case 13
80 year-old White UK male
Lived with wife
Living in urban area in England
1
Case 13: May 2007
Admitted via GP with:
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•
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•
2
Acute confusion
History of recent weight loss
Unwell for 10 months
Reduced mobility
One episode of urinary incontinence
? malignancy
Case 13: PMH
TURP 1996
Chest infection 2000
Chest infection 2002
Fungal nail infection 2006
Glaucoma 2006
Pacemaker fitted 2006 - noted to have mass in
right side of neck
3
Case 13: May – Sept 2007
OE:
• Obvious wasting
• Mass in right side of neck, (biopsy result from
previous week inconclusive)
• Rest of exam normal
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Case 13: May – Sept 2007
Investigations:
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Lymphocyte count 0.9
Na 124
Quantiferon negative
CT inflammatory mass
Case 13: May – Sept 2007
Further investigations:
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Repeat biopsy-atypical AAFBs
Referred to ID
Started on TB meds
Noted to have oral candida
Case 13: May – Sept 2007
On questioning:
• Disclosed sexual contact in Thailand in 1990
- male and female partners
• HIV test positive
• CD4 70
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Case 13: May – Sept 2007
Further course of illness:
• Started on antiretrovirals and PCP prophylaxis
• CD4 210 after 3/12 treatment
• Remained confused
- ? AIDS related dementia
• Unable to discharge home
• Discharged to nursing home
• Died 2008
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Case 13: summary
1996
2000
2002
2006
2006
2006
Admitted for surgery - TURP
Seen for chest infection
Seen for chest infection
Seen for fungal nail infections
Seen for glaucoma
Admitted for surgery – pacemaker
- mass on right side of neck noted
2007 Admitted via GP with:
- 10 month history weight loss, dementia, lymphopenia
high risk sexual contact in high prevalence area
HIV diagnosed: oral candida, TB: CD4 70
Inpatient for 4 months
Nursing home for 9 months
9
Q: At which of his healthcare interactions
could HIV testing have been performed?
1.
2.
3.
4.
5.
6.
7.
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When he was admitted for TURP?
When he was seen for recurrent chest infections?
When he was found to have fungal nail infections?
When he was diagnosed with glaucoma?
When he was admitted to have a pacemaker fitted?
When he was admitted with a 10-month history of
unexplained weight loss and found to have dementia and
lymphopenia?
Should he have been referred to GUM to see a trained
counsellor before HIV testing?
Who can test?
11
Who to test?
12
Who to test?
13
Rates of HIV-infected persons accessing
HIV care by area of residence, 2007
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Source: Health Protection Agency, www.hpa.org.uk
Who to test?
2008 Report on the
global AIDS epidemic
HIV prevalence (%) in adults (15–49) in Asia, 2007
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Source: UNAIDS Global Report 2008, www.unaids.org
Who to test?
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Who to test?
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At least 5 missed opportunities!
If current guidelines used, HIV could have been
diagnosed 7 years earlier
1996
2000
2002
2006
2006
2006
Admitted for surgery - TURP
Seen for chest infection
Seen for chest infection
Seen for fungal nail infections
Seen for glaucoma
Admitted for surgery – pacemaker
- mass on right side of neck noted
2007 Admitted via GP with:
- 10 month history weight loss, dementia, lymphopenia
high risk sexual contact in high prevalence area
HIV diagnosed: oral candida, TB: CD4 70
Inpatient for 4 months
Nursing home for 9 months
18
Learning Points
• This patient appeared to be at low risk of HIV and
presented with problems common in older people
• With no behavioural risk factors in the initial medical
history, the otherwise excellent medical teams looking
after him did not think of HIV even when the diagnosis
seems obvious with hindsight
• He had numerous investigations and a nursing home
stay, causing him and his family much distress and
costing the NHS thousands of pounds
• A perceived lack of risk should not deter you from
offering a test when clinically indicated
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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
• HIV screening should be a routine test on presentation
of weight loss, dementia or lymphopenia of otherwise
unknown cause
• Some patients may not disclose that they have put
themselves at risk of HIV infection in the past
• Opt-out and routine HIV testing overcomes barriers for
staff and patients
20
Also contains
UK National Guidelines for HIV
Testing 2008
from BASHH/BHIVA/BIS
Available from:
[email protected]
or 020 7383 6345
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