Case 10

63 year-old white UK male

Living in non-urban Eastern England

Married

Grown-up children

1

Case 10: March 2006

Referred by GP to ED

Seen by medical team and admitted with:– Recurrent chest problems– Cough– SOB

2

Case 10: PMH

Seen by GP in Oct 2003 for itchy skin problems and diarrhoea

• Investigations: FBC– lymphopenia (1.3)– anaemia (12.9)– low total WBC (3.7)– platelets 115– Total protein increased with globulins of 42

(diffuse hypergammaglobulinaemia)

Referred to Dermatology OPD3

Case 10: PMH

Seen in Dermatology OPD• Diagnosed with seborrhoeic dermatitis• Treated with ketoconazole 2% cream• In view of GI symptoms and haematological

abnormalities Dermatology suggested urgent GI referral

Referred to Gastroenterology OPD

4

Case 10: PMH (cont.)

Seen in Gastroenterology OPD over 2004/05

• Numerous investigations• Low folate and B12• Treated with gluten-free diet but all tests for

coeliacs disease negative• Diarrhoea and weight loss continue• Upper endoscopy NAD• Colonoscopy December 2005 NAD

5

Case 10: March 2006

Investigations:• CXR fine widespread pulmonary infiltrates• ? Vasculitis ? Lymphangitis carcinomatosis

Patient anxious, deteriorating, family worried• Worsening SOB

Further investigations:• CXR – showed deterioration from the admission X-ray

with diffuse interstitial shadowing both lung fields • ? Pulmonary Embolism• Angiogram done – no abnormality/evidence of PE seen

6

Case 10: April 2006

Radiologist doing angiogram queried appearance of CXR

•? typical of PCP

GUM asked to see ‘just in case’

•Patient seen on ward – moribund

Transferred to ITU immediately

7

Case 10: ITU April 2006

• HIV test positive - CD4 = 40• PCP, influenza, CMV pneumonia and

gastroenteritis, herpes simplex virus proctitis, candidiasis and C.difficile

• Extremely unwell for some weeks• Nearly died• Eventually recovered and discharged• Doing well on antiretroviral therapy (ART)

8

Case 10: summary

2003 Seen by GP for itchy skin problems and diarrhoea, found to have lymphopenia

2003 Seen in Dermatology OPD for seborrhoeic dermatitis

2004-2005 Seen in Gastroenterology OPD with recurrent diarrhoea and weight loss

March 2006 Admitted with recurrent chest infections, SOB

April 2006 PCP, CMV, HSV, oral candidiasis

HIV diagnosed: CD4 40

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Q: At which of his healthcare interactions could HIV testing have been performed?

1. When his GP detected lymphopenia?2. When he was seen in Dermatology for seborrhoeic

dermatitis?3. When he was seen in Gastroenterology OPD for recurrent

diarrhoea and weight loss?4. When he was admitted with recurrent chest problems?5. When he was investigated following abnormal CXR?6. Should he have been referred to GUM to see a trained

counsellor before HIV testing?

10

Who can test?

11

Who can test?

Who to test?

12

Who to test?

13

At least 4 missed opportunities!If current guidelines used, HIV diagnosed 2.5 years earlier

2003 Seen by GP for itchy skin problems and diarrhoea, found to have

lymphopenia

2003 Seen in Dermatology OPD forseborrhoeic dermatitis

2004-2005 Seen in Gastroenterology OPD with recurrent diarrhoea and weight loss

March 2006 Admitted with recurrent chest infections, SOB

April 2006 PCP, CMV, HSV, oral candidiasis

HIV diagnosed (CD4 40)14

Learning Points

• This patient had numerous investigations and a long ITU stay, causing him and his family much distress and costing the NHS thousands of pounds

• Because of his nadir CD4 of 40 he has an increased risk of potential problems despite control of his HIV now

• He did not disclose any risk factors when his initial medical history was taken

• Because of this the otherwise excellent medical teams looking after him did not think of HIV even when the diagnosis seems obvious with hindsight

• 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

• UK guidelines recommend routine offer of an HIV test for patients with lymphopenia

• HIV screening should become a routine test performed whenever there is a clinical indicator such as chronic diarrhoea or weight loss

• Some patients may not disclose that they have put themselves at risk of HIV infection in the past

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Also contains

UK National Guidelines for HIV Testing 2008

from BASHH/BHIVA/BIS

Available from:

enquiries@medfash.bma.org.uk or 020 7383 6345