Transcript Session 16 - Teaching Slides

Prolonged Fever and
Wasting Syndrome
HAIVN
Harvard Medical School AIDS
Initiative in Vietnam
1
Learning Objectives
By the end of this session, participants
should be able to:
 Outline causes of fever in an HIV
patient
 Describe causes of wasting syndrome
in an HIV patient
 Explain the process for diagnosing,
testing and treating prolonged fever
and wasting
2
What is the Definition of
“Prolonged Fever”?
Who is at Risk?
3
Overview of Prolonged Fever in
PLHIV (1)

Fever over 38.5 C lasting for more
than 14 days without any
determined cause
• Common in PLHIV, particularly those
with advanced disease
• If the CD4 count is low, more than one
infection or process may be present
• High grade fevers with other symptoms
are often due to another process, not
HIV itself
4
Overview of Prolonged Fever in
PLHIV (2)

Factors influencing initial differential
diagnosis of fever:
•
•
•
•
•
•
•
CD4 count/WHO staging
Course (acute vs. chronic)
Common OIs in the region
Patient’s personal OI history
Infections in selected population (i.e. IDU)
Localizing signs and symptoms
ARV (risk for IRIS)
5
Fevers in HIV Patients: Infectious
and Non-Infectious Etiologies
Category
Type
Etiology
Most
Common
Infectious
Etiologies
Mycobacterial
• TB
Fungal
• Penicilliosis
• Cryptococcosis
Bacterial
• Salmonellosis
Parasitic
• Toxoplasmosis
• Malaria
Neoplasia
• Lymphoma
Miscellaneous
• Drug reaction
6
• IRIS
NonInfectious
Etiologies
Differential Diagnosis by CD4
John Bartlett, Medical management of HIV Infection, 2004
CD4 <50
•
•
•
•
TB
Penicillium marneffei
Disseminated MAC
CMV (retinitis, colitis, esophagitis)
CD4 < 100
•
•
•
•
TB
Toxoplasmosis
Cryptococcosis
Histoplasmosis
CD4 < 200
• TB
• PCP
CD4 >200
• TB
• Bacterial infections, especially Strep
pneumonia
7
Approaching a Patient With
Fever and HIV (1)

When a PLHIV presents with fever
providers should:
• Take a history
• Perform a physical examination
• Conduct baseline tests

Taking a thorough history and
conducting a physical exam give
important clues about the diagnosis
8
Approaching a Patient With
Fever and HIV (2)
What should providers look for
when taking a patient history
and conducting the physical
exam?
9
History
When taking a history it is important
to find out about:
Category
Specifics
Fevers:
•
•
•
•
•
Localizing symptoms:
Duration
Pattern
Grade
Pain
Headache
General symptoms:
• Weight loss
• Night sweats
Associated
information:
• History of OIs
• Drug use
• Sexual history, etc
10
Physical Examination
Gen
Skin
HEENT
Lymph
nodes
Lungs
Heart
cachexia
rash, skin lesions
oral lesions
enlarged LN, including cervical, axillary,
inguinal regions
tachypnea, abnormal lung sounds
tachycardia, distant heart sounds, murmurs
Abdomen hepatosplenomegaly, ascites
Neuro
focal neurological deficits, altered mental
11
status
Baseline Tests
Some of the most common tests
include:
 CBC, chemistries, liver function tests
 CD4 count
 CXR and sputum smear for AFB x 3
 Fine needle aspiration of lymph node
 Blood cultures
 Urinalysis
12
Empiric Treatment (1)



Empiric treatment = treatment
before making a definite diagnosis
Treat with antibiotics for common
OIs or according to symptoms
Avoid quinolones if TB is a
consideration
• Monotherapy partially treats TB and
MAC, making diagnosis more difficult
and resistance more likely
13
Empiric Treatment (2)


If patient improves, continue
treatment
If no improvement:
• RE-EVALUATE to look for new signs or
symptoms
• Repeat tests and cultures
• Repeat AFB smears if TB possible
• Consider ARV (if indicated)
14
Supportive Treatment




Treat fever with paracetamol or
NSAIDS
If dehydration present: give IV fluids
until patient able to take oral hydration
Adequate nutrition
ARV may be best treatment if:
• work-ups negative, and
• patient not improved on empirical
treatment (beware of risk of IRIS)
15
Group Activity:
Review of Algorithm for
Diagnosis and Treatment
of PLHIV
16
Wasting Syndrome
17
AIDS Wasting Syndrome:
Definition


Involuntary loss of more than 10%
of body weight, plus more than 30
days of either diarrhea, or weakness
and fever
In the absence of another illness or
condition other than HIV infection
that could explain the findings
Source: US Centers for Disease Control (CDC)
18
18
AIDS Wasting Syndrome
19
Group Brainstorm:
What are some of the
causes of wasting in
PLHIV?
20
Etiology (1)
Low food intake:
Category
Symptom
Low appetite
• drugs have to be taken with
an empty stomach
Drug side effects
• nausea
• changes in the sense of taste
OIs in mouth or
• painful to eat
throat
Lack of money or • may make it difficult to shop
energy
for food or prepare meals 21
Etiology (2)

Poor nutrient absorption:
• Many infections interfere with this
process
• HIV may directly affect intestinal lining
• Diarrhea

Altered metabolism:
• PLHIV need more calories just to
maintain body weight
22
Etiology (3)
Infection and Malignancy:
Category
Causes
Mycobacteria
• TB
• MAC
Fungi
•
•
•
•
•
•
•
•
•
Virus
Parasitic diarrhea
Tumor
P. marneffei
Candida esophagitis
CMV
HIV
HSV (esophagitis)
Microsporidia
Isospora
Cryptosporidia
Lymphoma
23
Case Presentation




A 24 year old man presents with a 4
week history of fever, weight loss
and anorexia
Recently diagnosed with HIV at the
local VCT site
He denies any prior illnesses or
hospitalizations
He takes no medications and has no
allergies
24
What Other Information
do You Want at This
Time?
25
Clues From the History



Localizing
symptoms
Prior illnesses or
OIs
Reason for testing
for HIV


• Animals
• sick family
members
• unclean water
exposure
• due to OI?

Sexual history
Drug use history
Exposures

Occupation
26
Case (cont.)





Has lost 10 kg over 2 months
Cannot eat due to a very sore throat
Has no headache, diarrhea, abdominal
pain, cough or shortness of breath
Has not traveled
Has not worked for past 4 weeks
• previously worked as a motorbike
repairman

Denies any IDU
27
Case (cont.):
Physical Exam Findings






Vital signs: normal
General: cachetic
Oropharynx: thrush present
LN: bilateral cervical and axillary
lymphadenopathy (1-5 cm).
Skin: no rash
The rest of the exam is normal
28
Case (cont.):
Initial Laboratory Results







Hct: 28%
WBC: 4,200 (10%lympho)
LFTs: ALT 65, AST 60
Urinalysis: negative
CXR: very small left pleural effusion
otherwise negative
Sputum BK: negative X 3
CD4 count: 70
29
What is Your Initial
Diagnosis?

WHO Clinical Stage?
• Stage 3 (oral thrush, >10% weight loss)

Opportunistic infections?
• Oral candidiasis
• Possible esophageal candidiasis
• Lymphadenopathy (undetermined
etiology)

Other diagnoses?
• Anemia
30
What is the Cause of the Fever
and Lymphadenopathy?

Consider these
factors in your
differentials:
• WHO staging/CD4
• Oral and
esophageal
candidiasis are
indications of poor
immune function,
but do not usually
cause fever or
lymphadenopathy

Think of common
OIs in VN:
• TB, TB, TB
• Then fungi or
bacteria
• MAC (incidence is
unknown in VN)
31
Lymphadenopathy
Localized, usually
unilateral:
 Tuberculosis
 MAC
 Cryptococcus
 P. marneffei
 Bacteria
(Staphylococcus
aureus, anaerobes)
 Non-Hodgkin
lymphoma
Generalized,
multiple:
 HIV
 Tuberculosis
 MAC (rare)
 Syphilis
 Non-Hodgkins
lymphoma
 Kaposi Sarcoma
32
If No Localizing Symptoms



Blood culture for bacteria, fungus,
AFB
Biopsy of lymph nodes (if present)
Abdominal ultrasound may show
intra-abdominal lymph nodes or
hepatic/splenic enlargement
33
Case (cont.)

What would you do next?
• The patient had an aspiration of the
axillary lymph node
• BK stain: positive

What does that mean?
• He has TB
• He was started on 4 drugs for TB and is
now doing well
34
Key Points


Fever is common in HIV patients
Prolonged fever may indicate an
underlying infectious etiology
• Appropriate work-ups should be done
• Empiric treatment can be given if no
definite diagnosis is made
• Patients with negative work-ups should be
re-evaluated with repeat clinical exams and
diagnostic testing

Most common cause of prolonged
fever and wasting is TB
35
Thank you!
Questions?
36