case study cloete van vuuren id physician. 50 year old male abscess over l parotid gland cryptoccal...
DESCRIPTION
Pus aspirated – ZN pos, GeneXpert Rif ResistantTRANSCRIPT
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Case Study
Cloete van VuurenID Physician
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50 year old male
• Abscess over L parotid gland• Cryptoccal meningitis 2010• PTB 2010 – completed 6/12 of Rx• Stopped TDF/FTC/Efv 1 year ago
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• Pus aspirated – ZN pos, GeneXpert Rif Resistant
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4
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• Sputum culture – Rif, INH resistant – Aminoglycoside and Moxifloxacin sensitive
• Initiated onAmikacinMoxifloxacinTeridizoneEthionamidePZA
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ART
• 50 year old male• Weight 33 kg• CD4 = 49• sCreat = 70• Hemoglobin = 6.4• Calculated Creat clearance = 48.9• Unable to walk
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Which ART Regime do you initiate this patient on?
1. Tenofovir/Emtricabine/Efavirenz2. Zidovudine/lamivudine/Efavirenz3. Stavudine/Lamivudine/Efavirenz4. 2NRTI + Nevirapine5. 2 NRTI + Aluvia
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Delirium
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Delirium?
1. Chronically ill and debilitated2. Alcohol withdrawal3. Secondary infection4. Medication5. Other
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Which one of the following drugs is the most likely cause of his delirium?
1. Efavirenz2. Moxifloxacin3. Teridizone4. Pyrazinamide5. Ethionamide
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Desperately trying to sort out his delirium:
• Biochemically normal• No other infection identified• Switched to Nevirapine• Stop all TB drugs• Haloperidol
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Which side effects should be routinely monitored during the injection phase?
1. Renal function2. Hearing test3. Thyroid function4. Liver function5. Fullblood count
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Delirium
DVT
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Is DVT’s associated with Tuberculosis or TB Rx?
1. Yes2. No
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Series1
0
2
4
6
8
10
INRWarfarin
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Month 3 on MDR TB Rx:
• Due to his delirium it is impossible to do a hearing test
• Creatinine – 150• Hemoglobin increased to 10 g/dl• Sputum culture negative
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His Creatinine rises to 230 – will you stop the Amikacin?
1. Yes 2. No
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Month 6
• Can sit out – walk short distances• Gaining weight 31kg – 45 kg• More orientated• Monthly sputum TB cultures negative• Efavirenz – no effect on delirium
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“BILATERAL SYMETRICAL HGH FREQ SNHL SEVERE TO PROFOUND (HEARING AID NEEDED)BUT HE DOESN’T WANT A HEARING AID.”
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Discharge
• Will come to work daily – only “non-strenous”work• Will DOT at ward
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• Does not come regularly for medication• Often smells of alcohol• Family?• Social worker involved
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Virological failure?
1. Switch to AZT/3TC/Aluvia2. Request Genotype3. Tenofovir/3TC/Aluvia4. Other
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Adherence intervention
• DOT ART in the morning with MDRTB treatment
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K103N, M184V
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K103N, M184V
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• Disappeared for a month
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Why is this patient not taking his treatment?
1. Treatment illiteracy2. Social circumstances3. Poor support4. Mood disorders5. Alcohol abuse
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• HIV Dementia
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Conclusion
• Social circumstances• Alcohol• Delirium• DVT• HIV Dementia• TB/MDR TB vs HIV• “Human Nature”
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Case 2
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1. When did you initiate your first patient on ART?
1. <20042. 2004- 20073. 2008-200104. 2010 – 20155. None
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Depression
PN
MI
Cholesterol
In-stent thrombosis
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Aug10 Sep 11 Feb 12 Oct 13
Total Cholestero
l (mmol/l)
5.7 4.5 4.5 11.1
Trig (mmol/l)
56
HbA1C 11.5%
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Aug10
Sep 11 Feb 12 Oct 13 Mar14 Apr 15
TotalCholesterol
(mmol/l)
5.7 4.5 4.5 11.1 6.0 8.5
Trig (mmol/l)
56 19 32
HbA1C 11.5% 6.7% 7.3%
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Aug10 Sep11 Feb12 Oct 13 Mar14 Apr 15 Oct 15
Total Cholesterol
(mmol/l)
5.7 4.5 4.5 11.1 6.0 8.5 4.6
Trig (mmol/l)
56 19 32 1.2
HbA1C 11.5% 6.7% 7.3%
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Case 3
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In your experience, what is the most common reason for failing 2nd line ART?1. Not taking treatment2. Not absorbing3. Side effects4. Mood disorders5. Substance abuse
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M41L D67N V75IM M184V L210W T215Y A98G V106I Y188L
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Is she taking her treatment?
1. Yes2. No
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M41L D67N V75IM M184V L210W T215Y A98G V106I Y188L
RHZE
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What will you do?
1. Continue as is2. Tdf/FTC/Raltegravir3. Tdf/FTC/Raltegravir/Darunavir/r4. Other
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Conclusion
• Take nothing for granted• (Double check everything and everybody)