Transcript Clinicopathologic Conference

Clinicopathologic Conference
Advanced Update in HIV Medicine
and Clinical Research
October 1, 2009
Tammy M. Meyers, BA, MBBCh (WITS),
FCPaed (SA), Mmed, DTM&H
University of the Witwatersrand
Thumbi Ndung'u, DVM, PhD.
Nelson R. Mandela School of Medicine
“A 7-year-old boy with elevated HIV
ribonucleic acid levels despite
antiretroviral medications”
Presentation of Case
Brian C. Zanoni, M.D.
History of Present Illness
• 7 year old HIV positive child on ART
transferred care to Sinikithemba Clinic
Past Medical History
• Birth history
– Full term normal spontaneous vaginal delivery
– 3.4 Kg
– Mother with prenatal care but no HIV testing
– Breastfed for 3 months
– Received all routine immunizations
• Including BCG
History of Present Illness
• At age 3 hospitalized for pneumonia
– Clinically diagnosed with pulmonary TB
– Completed 6 months of RIF, INH, PZA
History of Present Illness
• 5 years 10 months old admitted for
respiratory distress
– Mantoux negative
– HIV positive
– Treated with ceftriaxone, clarithromycin,
trimethoprim-sulfamethoxazole (TMP/SMX),
albuterol (salbutamol), and hydrocortisone
• No improvement
History of Present Illness
• Admission continued
– CD4: 9 / 1%
– VL: 2.2 million copies / ml
– Weight: 14 Kg (<5%)
– After 5 days of no improvement started on
RIF, INH, PZA for presumptive TB
– Began HAART with AZT, 3TC, Ritonavir
– Discharged on day 11
• Continued TMP/SMX, TB treatment, and ART
History of Present Illness
• 4 months later
– Developed a supraclavicular abscess
• No response to antibiotics
• I and D
– Culture: No growth (bacterial or mycobacterial)
– Pathology: Caseating granulomas with necrosis
» Consistent with TB
History of Present Illness
• 6 months after admission and ART/TB
Treatment
– Supraclavicular node resolved
– TB treatment stopped (6 months completed)
– CD4: 236 / 6% (↑ 9 / 1% at baseline)
– VL: 3342
– Weight: 15 kg (~3%)
History of Present Illness
• After 18 months on ART
– Unable to continue with private physician for
financial reasons
– Transferred to McCord Hospital Sinikithemba
Clinic
– Mother reported good adherence with ART
and TMP/SMX
– Patient was unaware of his HIV status
Social/Family History
• Father died of unknown illness when
patient was an infant
• Mother tested HIV positive after diagnosis
of patient
• Siblings tested HIV negative
• No known TB contacts
Presentation to Sinikithemba
• Physical exam
– Weight < 5%
– Axillary adenopathy
– Otherwise normal
• Preliminary management
– AZT dose increased
– 3TC dose increased
– Ritonavir changed to lopinavir/ritonavir
– TMP/SMX continued
Lab Results
• 18 Months on ART
– CD4: 146 / 6.1 %
– VL: 4300
– Hb: 10.6 MCV 96
– LFTs: Normal
Follow-up
• 5 months after presentation to Sinikithemba
– Mother reported good adherence
• No side effects
– CD4: 471 / 17.9%
– VL: 22,000 copies / ml
– Weight: 17.39 Kg (<5%)
• A diagnostic test was performed
Differential Diagnosis
Dr. Tammy M. Meyers
Discussion of Management
Dr. Tammy M. Meyers
Follow-up
Brian C. Zanoni, M.D.
Follow-up
• CD4 nadir 59 / 6%
• Darunavir – Obtained on a compassionate
basis from company
– Drug registered with Medicine Counsel
• Regimen changed:
– Darunavir 375 mg twice daily
– Ritonavir 100 mg twice daily
– EFV 300 mg daily
Follow-up
• 2 weeks later
– Developed fever, cough, and new right middle lobe
infiltrate
– Diagnosed with pneumonia
• Responded to oral antibiotics
• 8 weeks after change of regimen
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Clinically well
Weight: 21.43 Kg (5% - 10%)
CD4: 193 / 5.8%
VL: 150