Transcript Clinical Case #25

Clinical Case #25
Yvonne Josephine Banarez
Pharmacology -AOctober 12, 2006
-History 32 Year Old Man (Homosexual)
 3 month history of:
Weight Loss
Fatigue
 Intermittent Fever
 Intermittent Lymphadenopathy
 Progressive Increase of Diarrhea (1mo period)
 Occurrences of Severe SOB
 Non-Productive Cough: 3days
-PhysicalPatient is Febrile at 102˚F (38.9˚C)
 All Other Reports are Omitted
-Lab OrdersCBC w/ Differential
CXR
-Lab ResultsBlood work:
- CD4 Count: 180 u/mm³
Chest X-Ray
- Diffused Interstitial Infiltrate
** These were the only given results. **
All values omitted are assumed within normal range.
-Radiograph of Diffuse Interstitial Infiltrate-
Nodular Densities are Seen Throughout Both Lungs
-Differential Dx HIV/AIDS
- Based on lifestyle
- Hx. Of sudden weight loss and fatigue
- Hx. of lymphadenopathy
**Diagnostic: CD4 Count = 180!!
<500 reveals late stage HIV infection.
<200 indicative of AIDS.
Set Values Based on US Center for Disease Control
-Differential Dx Pneumonia
- Fever, SOB, Non-Productive Cough, CXR
revealed Diffuse Interstitial Filtrate
Types: Those closely related to AIDS
- Pneumocystis carinii (PCP)
- Cryptococcal neoformans (CNP)
 Mycobacterial Infection
Types: Tuberculosis
-DiscussionAIDS: coincides with patient’s symptoms, CD4
count, rapid Ig test, p24 Antigen Test or PCR
may be used to confirm
CNP: common w/ AIDS, but X-Ray of lungs do
not show infiltrates
TB: common w/ AIDS, shows infiltrates, but
mycobacterium infected coughs have phlegm
and/or blood. Patient states dry cough. Absence
of systemic symptoms also make Dx less likely
PCP: common w/ AIDS, shows infiltrates,
coincides w/ dry cough
-AIDS Treatment Highly Active Antiretroviral Therapy (HAART)
 Consists of combination or “cocktail” of 3 or more drugs from the 4 categories
1. Protease Inhibitors (PIs)
1. cleave precursor molecules results in production of immature viral particles
2. Nucleoside Reverse Transcriptase Inhibitors (NRTIs)
1. competitively inhibit HIV reverse transcriptase
2. incorporated into the growing viral DNA chain to cause termination
3. Non Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
1. bind to HIV reverse transcriptase and block RNA and DNA dependent DNA
polymerase activities
2. Different binding site from NRTIs
4. Entry Inhibitors
1. Prevents the penetration of the virus into the host cell
Protease Inhibitors
Drug
Adult Dosing
Aptivus® (tipranavir), by Boehringer
Ingelheim
Two 250mg capsules plus two 100mg Norvir capsules, twice a day (a total of 8 pills a
day).
Crixivan® (indinavir), by Merck & Co.
Two 400mg capsules, every 8 hours (a total of 6 pills a day), or two 400mg Crixivan
capsules with either one or two 100mg Norvir capsules twice a day (preferred
dosing).
Invirase® (saquinavir), by Hoffmann-La
Roche
Invirase must be used in combination with Norvir. The approved dose is two 500mg
Invirase tablets plus one 100mg Norvir capsule, twice a day (a total of 6 pills a
day).
Kaletra®* (lopinavir + ritonavir), by Abbott
Laboratories
* Also sold as Aluvia in some parts of the
world.
Two tablets, twice a day (a total of 4 pills a day), or, if starting therapy for the first time,
four tablets once a day (see Notes for exceptions). Each tablet contains 200mg
lopinavir + 50mg ritonavir.
Lexiva® (fosamprenavir), by
GlaxoSmithKline
Two 700mg tablets, twice a day (a total of 4 pills a day), or two 700mg tablets plus two
100mg Norvir capsules, once a day (a total of 4 pills a day), or one 700mg tablet
plus one 100mg Norvir capsule twice a day (a total of 4 pills a day). This last
dosing option should be used for patients who have tried and failed other
protease inhibitors in the past.
Norvir® (ritonavir), by Abbott Laboratories
Six 100mg capsules, twice a day* (a total of 12 pills a day). Start with 3 capsules, twice
a day, and increase to full dose over 14 days. Note: the full dose of Norvir is
rarely used any more. Norvir is most often used at much lower doses to "boost"
the levels of other protease inhibitors in the body.
Prezista™ (darunavir) by Tibotec
Prezista must be used in combination with Norvir. The approved dose is two 300mg
Prezista tablets plus one 100mg Norvir capsule, twice a day (a total of 6 pills a
day).
Reyataz® (atazanavir), by Bristol-Myers
Squibb
Two 200mg capsules, once a day (a total of 2 pills a day), or two 150mg capsules plus
one 100mg Norvir capsule, once a day (a total of 3 pills a day).
Viracept® (nelfinavir), by Pfizer
Two 625mg tablets, two times a day (a total of 4 pills a day), or five 250mg tablets,
twice a day, or three 250mg tablets, three times a day (a total of 9-10 pills a day).
NNRTIs
Drug
Adult Dosing
Atripla™ (Sustiva* + Viread + Emtriva), by Gilead Science
and Bristol-Myers Squibb
One tablet (contains 600mg Sustiva + 300mg Viread + 200mg
Emtriva), once a day (a total of one pill a day).
Combivir® (Retrovir + Epivir), by GlaxoSmithKline
One tablet (contains 300mg Retrovir + 150mg Epivir), twice a day (a
total of 2 pills a day)
Emtriva® (emtricitabine), by Gilead Sciences
One 200mg capsule once a day.
Epivir® (lamivudine; 3TC), by GlaxoSmithKline
One 300mg tablet, once a day, or one 150mg tablet, twice a day* (a
total of 1 or 2 pills a day)
Epzicom™* (Ziagen + Epivir), by GlaxoSmithKline
* Also sold as Kivexa in some parts of the world.
One tablet (contains 600mg Ziagen + 300mg Epivir), once a day
Retrovir® (zidovudine; AZT), by GlaxoSmithKline
One 300mg tablet, twice a day* (a total of 2 pills a day)
Trizivir® (Retrovir + Epivir + Ziagen), by GlaxoSmithKline
One tablet (contains 300mg Retrovir + 150mg Epivir + 300mg Ziagen),
twice a day (a total of 2 pills a day)
Truvada® (Viread + Emtriva), by Gilead Sciences
One tablet (contains 300mg Viread + 200mg Emtriva), once a day
Videx® (didanosine; ddI): buffered versions, by BristolMyers Squibb
Two 100mg tablets twice a day* (a total of 4 pills a day), or two 200mg
tablets, once a day (a total of 2 pills a day). For patients weighing less
than 133 lbs. (60 kg), click here.
Videx® EC (didanosine; ddI): delayed-release capsules,
by Bristol-Myers Squibb
One 400mg capsule once a day. For patients weighing less than 133
lbs. (60 kg), the dose is one 250mg capsule once a day.
Viread® (tenofovir DF), by Gilead Sciences
One 300mg tablet once a day.
Zerit® (stavudine; d4T), by Bristol-Myers Squibb
One 40mg capsule, every 12 hours (a total of 2 pills a day). For
patients weighing less than 133 lbs. (60 kg), click here.
Ziagen® (abacavir), by GlaxoSmithKline
One 300mg tablet twice a day, or two tablets once a day (a total of 2
pills a day)
NNRTIs
Drug
Adult Dosing
Atripla™ (Sustiva + Viread* +
Emtriva*), by Gilead
Science and Bristol-Myers
Squibb
* Viread and Emtriva are
nucleoside reverse
transcriptase inhibitors
(NNRTIs)
One tablet (contains 600mg Sustiva + 300mg Viread + 200mg
Emtriva), once a day (a total of one pill a day).
Rescriptor® (delavirdine), by
Pfizer
Two 200mg tablets, three times a day (a total of 6 pills a day)
Sustiva®* (efavirenz), by
Bristol-Myers Squibb
* Also sold as Stocrin in some
parts of the world.
One 600mg tablet once a day (just 1 pill a day)
Viramune® (nevirapine), by
Boehringer Ingelheim
One 200mg tablet per day for 14 days, then one 200mg tablet,
twice a day* (a total of 2 pills a day)
Fusion/ Entry Inhibitors
Drug
Fuzeon® (T-20), by Trimeris
and Hoffmann-La Roche
Adult Dosing
Two 90mg (in 1-ml solution) subcutaneous (under the skin)
injections a day.
-Diagnostic Procedures CD4 count of 180 implies AIDS. Standard retroviral treatments
can begin, that inhibit further replication of HIV. Unfortunately,
AIDS in not curable, and can only be slowed down – not stopped.
 Pneumocystis carinii pneumonia (PCP) is the most common
cause of an interstitial infiltrate in an HIV-infected patient with a
CD4 count less than 200/mm3. The patient was started on
presumptive therapy for PCP with
trimethoprim-sulfamethoxazole and prednisone.
 However, his clinical condition remained unchanged during
treatment, indicating a possible misdiagnosis! More lab tests
need to be ordered to be conclusive.
-Further Lab TestingA Bronchioscopy was ordered to visualize any
lesions or macroscopic structures possibly
causing respiratory distress.
Upon inspection, a transbronchial lung biopsy
was ordered. Pathological reports will then be
issued, possibly revealing the agent causing
pneumonia.
PCP can now be ruled out.
-ConclusionSince the exercise did not provide a report on the last two
tests ordered, a definitive diagnosis could not be obtained.
However, the fact that the authors included the order for a lung
biopsy, highly suggests that Malignancy is a strong
consideration.
A bothersome cough is a common feature of Kaposi's
sarcoma (KS), which, along with the symptoms and the X-Ray
findings, is most probable with homosexual men with AIDS.
Non Hodgkin’s Lymphoma is also a malignancy to be
considered with AIDS, but the X-Ray does not indicate such.
Should those assumptions be correct, the patient was started on
 vinca alkaloids – mitotic spindles
 Paclitaxel – mitotic spindles
 Etoposide - topoisomerase
 Anthracyclines - topoisomerase
 bleomycin
Which are all systemic chemotherapy drug used to treat KS
associated with HIV. A combination of these drugs is also a
possible treatment.
-Question 1 & 2What are the most likely infectious agents that
are causing the patient’s pneumonia? What are
the therapeutic options for each agent?
PCP
trimethoprim-sulfamethoxazole and prednisone
Mycobacterial Infection
Broad spectrum antibiotics and amphotericin B
Kaposi’s Sarcoma
 vinca alkaloids, Paclitaxel, Etoposide, Anthracyclines, bleomycin
-Question 3What are the most likely etiologic agents causing the
patients diarrhea? What are the therapeutic options?
 Malabsorptive Syndrome
AIDS treatment
 Fungi – cryptosporidium, isosporabelli or
microsporidia
Amphotericin B
 Bacteria – salmonella, shingella
Broad spectrum antibiotics
THANKS…