Case 6

58 year-old man from North America

Married

Recently moved to London

1

Case 6: late 2005

Registered with GP - new patient check:• Lipids normal• Random glucose normal• FBC normal - incidental finding: low platelets

Referred to Haematology OPD

2

Seen in Haematology OPD (wife present)

Investigations:• Platelet count 65 x 109/l (150 - 400 x 109/l)• No other symptoms• Patient stated: “No risk factors for HIV”• HIV test not performed• Bone marrow aspirate and trephine

(megakaryocytes present consistent with peripheral destruction/consumption)

3

Case 6: late 2005

Case 6: late 2005

Diagnosis:• ‘Auto-immune thrombocytopenia’

Plan:• Observe• GP to monitor platelet count • No plan for active treatment

4

Patient re-referred by GP to Haematology• Platelet count 56 x 109/l (150 - 400 x 109/l)• Weight loss

Reviewed by Gastroenterologist/Urologist• OGD, Colonoscopy, Cystoscopy performed: NAD• Patient stated: “No risk factors for HIV”

5

Case 6: late 2006

• HIV test (after counselling): positive• Patient recalls being bisexual in 1980s/1990s

and since• Referral to HIV team

– CD4 146 (5%)– VL 94,000– No opportunistic infection

• Antiretroviral therapy commenced

6

Case 6: late 2006

Case 6: summary

2005 Registered with GP, referral, low platelets

2005 Seen in Haematology, thrombocytopenia

2006 Re-referred to Haematology, low platelets

2006 Seen by Gastroenterology and Urology for weight loss

2006 HIV diagnosed: CD4 146: VL 94,000

7

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

1. When he registered with his GP and was referred to Haematology?

2. When he was first seen in Haematology?

3. When he was seen by Gastroenterology and Urology for weight loss?

4. Only after being referred to GUM for counselling before HIV testing?

8

Who can test?

9

Who to test?

10

11

Who to test?

12

Rates of HIV-infected persons accessingHIV care by area of residence, 2007

Source: Health Protection Agency, www.hpa.org.uk

Who to test?

13

2005 Registered with GP, referral, low platelets

2005 Seen in Haematology, thrombocytopenia

2006 Re-referred to Haematology, low platelets

2006 Seen by Gastroenterology and Urology for weight loss

2006 HIV diagnosed: CD4 146: VL 94,000

14

4 missed opportunities!If current guidelines used, HIV could have been diagnosed at least 13 months earlier

15

Anaemia Thrombocytopenia

Lymphoma

HIV

Neutropenia

Haematological presentationsin HIV infection

• Mode of presentation in ~ 10% (Sullivan et al, 1997)

• Thrombocytopenia in ~ 40% of patients – Platelet count < 50 x 109/l in 1 - 5% cases

• Isolated thrombocytopenia– does not affect overall prognosis (Holzman et al, 1987)

• May be managed differently from HIV negative patients

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Thrombocytopenia in HIV+

Mechanisms underlying thrombocytopenia

• Reduced production THINK HIV!• Generalised bone marrow failure• Selective megakaryocyte defects

• Increased consumption THINK HIV!• Immune• Disseminated intravascular coagulation (DIC)• Thrombotic thrombocytopenia purpura (TTP)

• Abnormal distribution• Sequestration (splenomegaly: infection, haemophagocytosis, cirrhosis)

• Dilutional17

Classification of anaemias

18

Microcytic, hypochromic Normocytic, normochromic Macrocytic

MCV < 80 fl MCV 80 – 95 fl MCV > 95 fl

MCH < 27 pg MCH > 27pg

Fe deficiency Haemolytic anaemias Megaloblastic

(immune, HUS, TTP, G6PD) B12 + folate

Thalassaemia Acute blood loss Alcohol

Lead poisoning Mixed deficiency Liver disease

Sideroblastic anaemia Parvovirus, Infection (MAI) Myelodysplasia

Drugs (septrin, dapsone, GCV) Drugs (AZT)

ANAEMIA OF CHRONIC DISEASE HIV infection

• This man did not have an obvious risk factor when a medical history was initially taken

• He had put himself at risk in the past but did not share this with anyone on routine questioning in outpatients as his wife was present

• 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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Learning Points

• The benefits of early diagnosis of HIV are well recognised - not offering HIV testing represents a missed opportunity

• UK guidelines recommend screening for HIV in adult populations where undiagnosed prevalence is >1/1000 as it has been shown to be cost-effective

• UK guidelines recommend routine opt-out HIV testing for patients with thrombocytopenia

• HIV screening should become a routine test when investigating PUO, chronic diarrhoea or weight loss of otherwise unknown cause

• UK guidelines recommend universal HIV testing for patients from groups at higher risk of HIV infection

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Key messages

21

Also contains

UK National Guidelines for HIV Testing 2008

from BASHH/BHIVA/BIS

Available from:

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