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CASE STUDY
Oluremi Famodu
WVU Dietetic Intern
OUTLINE
The Patient
 HIV (Background/Prevalence)
 HIV and Wasting Syndrome
 Nutrition and HIV
 Nutrition Assessment of Patient

Diagnosis
 Intervention
 Monitoring and Evaluation

PATIENT DEMOGRAPHICS
50 yo ♂
 52.7 kg (115.9 pounds)
 5’11’’ (180.34 cm)
 BMI 16.2 – Protein/Energy Malnutrition Grade II
 Ideal Wt: 75.3 kg (165.7 pounds)
 70% IBW
 Former smoker and drinker

PATIENT MEDICAL HISTORY
Past Medical Hx



HIV
PEG tube placement
Bilateral Hip replacement
Current Medical Hx








HIV positive
Possible Tuberculosis (TB)
>110 pound weight loss in
5 years
Cachexia (Wasting
Syndrome)
Weakness
s/p PEG placement
Pancytopenia
Hyponatremia
THE VIRUS
THE HUMAN IMMUNODEFICIENCY VIRUS
(HIV)

Zoonotic retrovirus (transfer between species:
monkey  human)

Rapid or severe loss of CD4+ T lymphocytes
Lentivirus (slow replicating)
 Causes Acquired Immunodeficiency Syndrome
(AIDS)



Progressive failure of the immune system allowing
life-threatening opportunistic infections and cancers
to thrive
No cure…but it can be controlled!

Average life expectancy for untreated HIV= 10 years
HIV TIME COURSE
HIV/AIDS PANDEMIC



Over one million people
living with HIV/AIDS in
the United States (CDC)
1 in 5 people living with
HIV are unaware of
infection (~18% in the
U.S.)
Having long-term
controlled HIV infection
shows ↑ risk of
Cardiovascular disease
and
Osteoporosis/Osteopenia
HIV NUTRITION &
COMPLICATIONS
Wasting Syndrome
WASTING SYNDROME/DISEASE

Defined as
Involuntary weight loss (skeletal muscle and adipose
tissue) greater than 10% from baseline OR
 Chronic diarrhea OR
 Documented fever for more than 30 days
 AND associated weakness

In 2002, wasting incidence rates as high as
10.6/100 in HIV-infected women.
 Nutrition for Healthy Living Cohort: 33.6%
incidence rate in 2000.

WASTING SYNDROME CONT.
↑ rate of survival if overweight or obese
 Presence of opportunistic infection:

Opportunistic
infection
Weight loss and
wasting = ↑
Mortality
Breakdown of
volatile protein
stores (muscle
tissue)
Activation of
immune functions
and healing
processes
↓ appetite
Small proteins
formed;
inflammation
response
CLINICAL FINDINGS CONSISTENT WITH
WASTING DISEASE
Subjective
Physical Findings


√
Lethargy

Anorexia

Food Insecurity

Loose Fitting Clothing


Physical Function


Vital Signs
√ Unintentional weight loss

√ >10%

>5% within 6 months
√ BMI


<18.5 or marked decline from usual
BMI



Mid-upper arm circumference

<10th NHANES percentile
Subclavicular muscle loss, angular
shoulders, visible articulations of ribs
at junction with sternum
Sacral edema (in bed rest/bound
patient)
Extremities


Temporal wasting, periocular edema
or fat loss, prominent zygomatic
process
Torso

Difficulty or inability to stand w/o
assistance

Head

Diminished mass interosseous dorsalis
when pressing thumb to forefinger
Diminished mass quadriceps femoris
and vastus medialis when leg bent at
right angle
Delayed mid-upper arm skin fold
return, loss of turgor
Lower extremity edema
HIV AND NUTRITION

Maintaining good nutrition may help:







Limit weight loss
Reduce risk of infections
Diarrhea
Lipodystrophy (fat distribution syndrome)
Limit nutrient deficiencies
Help process medications and manage side effects
Keep immune system stronger
BASIC PRINCIPLES OF HIV AND
NUTRITION



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General Healthy Diet
 High in vegetables, fruits, whole grains and legumes
 Choosing lean, low-fat sources of protein
 Limiting sweets, soft drinks, and foods with added sugar
 Balanced meals: protein + carbohydrate + little good fat
 Multivitamin-Vitamin A, C, E, B Vitamins, Selenium
and Zinc
High-Energy
High-Protein
 1.5 g/kg
Mediterranean Diet?
Physical Activity
NUTRITION ASSESSMENT
Diagnosis
Intervention
Monitoring and Evaluation
INITIAL ASSESSMENT
Assessing for:
 Admitting diagnosis of HIV
 Albumin <2.5,
 New Tube Feed
 Braden Scale Score = 21; No skin breakdown
 IV Fluids: NS @ 100mL/hour
 Receiving folic acid
 Regular diet

INITIAL ASSESSMENT CONT.
Sister and mom state concerns for pt’s mental
status and not able to take care of him
 Conflicting reports of 110# weight loss over 8
months versus 5 years per H&P and MD notes
 Per physician, pt on nightly tube feed regimen
(unsure of formula)

NUTRITION ASSESSMENT: MEDICATIONS
Medication
Pharmacologic Action
Prezista
Antiretoviral (HIV/AIDS)
Diflucan
Antifungal
Isentress
Antiretoviral (HIV/AIDS)
Zantac
Antiulcer, AntiGERD, Antisecretory
Zofran PRN
Antiemetic, Antinauseant
Klor-Con PRN
Potassium Supplement
Senokot-S PRN
Stimulant Laxative; Stool Softener
Zithromax
Antibiotic
Dapsone
Antibacterial
Neupogen
Colony Stimulating Factor
Zosyn
Antibiotic
Vancomysoin
Antibiotic
NUTRITION ASSESSMENT: LAB VALUES
Constituent Reference
Admission Values
Cause/Significance
Glucose
70-99 mg/dL
92 mg/dL
---
BUN
8-23 mg/dL
9 mg/dL
---
0.6-1.2 mg/dL
0.5 mg/dL---L
GFR
85-125 mL/min
>60 mL/min
---
Magnesium
1.8-2.6 mEq/L
1.5 mEq/L---L
Malabsorption; Malnutrition
3.5-5 gm/dL
2.7 gm/dL---L
Malabsorption;
Malnutrition; ↓ protein
intake; acute illness/stress
3200-10,600/μL
1600/μL---L
Creatinine
Albumin
WBC
RBC
Hb
HCT
Decrease in muscle mass;
↓ protein intake
HIV/AIDS
4.7-6.1 million/mm3 3.73 million/mm3---L Anemia
14.6-17.5 g/dL
12.1 g/dL---L
Anemia; HIV/AIDS
41-51%
35.9% ---L
Anemia; Blood loss
SUBJECTIVE: THE CALL
(UNABLE TO VISIT 2° TO TB PRECAUTIONS)
“Lost 110# in 2 years”
 Top weight 216#; ↓ after bit by a recluse spider
 Reports good appetite and cooks for himself
 Has PEG tube for medication administration 2°
to pill dysphagia
 “I put (pureed) Cornish hens, corn dogs, and
protein supplements down PEG tube”
 Unsure of home tube feeding formula

DIAGNOSIS
Problem = Underweight
Etiology = related to HIV
Symptoms = as evidenced by need
for supplemental enteral
nutrition
INTERVENTION

Estimated Energy


35-40 kcal/kg: 1855-2120 kcal
Estimated Protein

1.4-1.6 g/kg: 74-85 grams
Risk
Score
Nutrition Support
6
BMI <18.5
2
Weight Loss
2
Admitting Diagnosis
2
Total = 12 (High Risk)
INTERVENTION
Nutrition Goals
Improve protein status
Improve po intake
Intake of ≥ 50%
Tolerate po diet

Recommend initiating nightly tube feedings
 Boost Plus 60mL/hour over 12 hours (20:00-8:00)

1080 calories, 42 grams of protein and 555 mL water
Initiate Calorie Count x 3 days
 Monitor and encourage adequate po intake
 Monitor weight and labs
 Recommend education on proper PEG tube feeding/care
before discharge
 IPOC

MONITOR & EVALUATE

Po intake per RN note
Meal

11/4/2013
11/05/2013
11/08/2013
Breakfast
50-75%
75-100%
75-100%
Lunch
25-50%
75-100%
0-25%
Dinner
---
---
---
Weight
11/3/2013
11/05/2013
11/08/2013
52.7 kg
50.6 kg
53 kg
Bed Scale
Standing Scale
Standing Scale
Estimated
Calorie Needs
Estimated
Protein Needs (g)
1855-2120
74-85
MONITOR & EVALUATE

Calorie Count and Tube Feeding
Date
11/06/2013
11/07/2013
11/08/2013
Daily Total
Calories
1670
600
190
Daily Total
Protein
67
17
7
% Estimated
Calories Met
90
32
10
% Estimated
Protein Met
91
23
9
Comment
Tube feeding
provided
1080 calories
and 42 g
protein.
No intake recorded
for lunch or dinner.
Tube feeding ran
from 2000-2400
turned off d/t NPO.
TF recorded under
dinner slot.
No intake recorded for
breakfast or dinner. Pt
receiving TF from 20000800 but has been
messing with pump. Pt
changing rate
throughout night.
Estimated
Calorie Needs
Estimated
Protein Needs (g)
1855-2120
74-85
MONITOR AND EVALUATE

Calorie Count & Tube Feed Assessment

Average calorie intake = 44%


816 calories
Average protein intake = 41%

30 g protein
MONITOR AND EVALUATE

Labs
Constituent
Admission Values
Discharge Values
Glucose
92 mg/dL
74 mg/dL
BUN
9 mg/dL
6 mg/dL---L
0.5 mg/dL---L
0.5 mg/dL---L
>60 mL/min
> 60 mL/min
Magnesium
1.5 mEq/L---L
---
Albumin
2.7 gm/dL---L
---
WBC
1600/μL---L
1400/μL---L
RBC
3.73 million/mm3---L
2.81 million/mm3---L
12.1 g/dL---L
9.1 g/dL---L
35.9% ---L
27.6%---L
Creatinine
GFR
Hb
HCT
ENDING DIAGNOSIS
Lung masses (two cavity) s/p bronchoscopy; no
hemoptysis or persistent coughing
 HIV/AIDS treatment
 Hyponatremia --- resolved
 Hypokalemia --- resolved
 Malnutrition with cachexia, 2° to mass & HIV
 Pancytopenia 2° to HIV
 Chronic pancreatitis

WHERE IS HE NOW?

Key West?
OR

Camper in Clendenin?


To be continued…
REFERENCES
Centers for Disease Control and Prevention:
http://www.cdc.gov/hiv
 http://www.webmd.com/hivaids
 www.aidsinfonet.org
 Fazia, A. (2012, October 01). Hiv and nutrition.
http://emedicine.medscape.com/article/2058483overview
 AND Nutrition Care Manual
 Mahan LK, Escott-Stump S. Krause’s Food and
Nutrition Therapy: 12th ed. 2008

QUESTIONS?