Challenging cases in HIV medicine

Dr Ashwini Tayade

Case 1

• 40/male

• HIV positive

• July 2014

-wt loss 10kg in 1 yrs

-low grade fever

- eruptions/rashes over face 3 mths

- - cough

• Diagnosis – 2004 during routine check up

CD4 count - 234(15.2%)

VL - ?

started on ZDV/3TC/NVP

stopped ART after 1 yr

Next follow up

• May 2007

CD4 -227(18%)

VL - 151381

started on Duovir E kit daily

discontinued after taking for 3 years

• Examination

-nodular eruptions over face

-Enlarged lt supraclavicular and lt cervical LN

Labs

• CD 4 – 71 (13%)

• VL – 9,07,490copies/ml

CBC

Hb 4.9

TC 5650

PC 95000

S.Creat-0.9

ESR 140

Peripheral smear – microcytic hypochromic RBCs

Skin leisons

Chest x-ray

Diagnosis

• HIV/AIDS CDC-C, WHO IV ( C/I/V failure)

• OI- Lymphadenitis /lung infiltrate

• Severe anemia/bicytopenia

• Skin leisons

2004 2005 2014

CD4 516(23.8%) 555(23.8%) 119(11%)

Viral load 22,644 1,324,239

• 1.molluscum contagiosum/tb

• 2.TB

• 3.lymphoma

• 4.need biopsy/further test to confirm

• Treatment of OI

?Empirical ATT vs Tissue diagnosis

• ART

- when?

- what regimen?

Plan

• Plan to start PI based regimen

• Empirical ATT

-rifabutin based regimen

• Rifabutin/INH/E/Z

• LN FNAC - AFB smear -negative

Xpert MTB-negative

• ??

Reconsideration of plan

• ??ATT

• Treatment of histoplasma

• ??ART

• ATT stopped

• Itraconazole started

• ART??

- when to start?

- what regimen?

Which ART ? MUTATIONS ?

• 2NRTI+NNRTI

• 2NRTI+PI

• 2NRTI+Integrase inhibitor3TC/AZT/D4T/NVP/EFV

• Tenofovir /emtricitabin/raltegravir

Special Considerations with Regard to

Starting ART

• Started on ART as soon as possible after initiating antifungal therapy (AIII).

• IRIS is reportedly uncommon in HIV-infected patients with histoplasmosis.

• ART should, therefore, not be withheld because of concern for the possible development of IRIS (AIII).

All of the triazole antifungals have the potential for complex, and possibly bidirectional, interactions with certain ARV agents and other anti-infective agents.

Case 2

• 35/male,

• Diagnosed HIV positive 2004

• cd4 -?

• Started on Lamivir-S/EFV-2008 (40/6%)

• Stopped on his own after 2 yrs

• Personal-

owns some property business/partially in politics

married-wife positive

2 kids- negative

gutakha(tobacco),alcohol

MSC

OI- Oral candidiasis

2011

• Chronic diarrhea – work up for OI – negative

• Cd4- 67 (4%)

• Counselled

• Reconfirmed –HIV 1

• Genotype testing was sent -

• Mutations expected?

• New regimen ?

• NRTI- K70E,M184V

• NNRTI- K103N,P225H

TDF/FTC/ATV/RT

V

• Was started on –

• INH prophylaxis

• Took for 1-2 yrs – stopped

• And switched to ayurvedic treatment

2014

• Chronic cough –

• Seen a pulmonologist

• Treated for Pneumocystis and ? NSIP ( no biopsy )(9/5/14- 15/5/14)

• subsequently put on bronchodilators

• And oral steroids intermittently

• Courses of - Clarithromycin, levofloxacin, cotrim

• No relief

• Cd4-??????

• VL- ??????? Stopped ayurvedic as

well

2015(25/3-30/4)

• Persistent cough ,

• Loss of appetite

• Lethargy

• Weight loss

• Difficulty in swallowing

• Exam- oral thrush , no LN ,

• SYST- irritable , disoriented ,no FND, no CN palsy

Labs-

• CBC-10.8/5100/2.63

• LFT- 1/42/22/77

• s.Create- 0.9

• hbsAg,HCV, VDRL – neg

• Chest X ray- normal

• Usg abd – normal

• CD4-4(1%)

• VL – 778050 copies On the day of admission ,he had seizure and

transient loss of consciouness

Possibilities ? What next ?

• 1.TOXOPLASMOSIS

• 2.TB

• 3.CNS LYMPHOMA

• 4.CRYPTOCOCCOMAS

• 5.ASPERGILLUS

• 6.NOCARDIA

• Toxoplasma IgG- >200 IU/ml

• CRAG – Neg

• CSF- sugar- 33.1mg/dl

protein- 41.1 mg/dl

rbs- 101 mg/dl

2-3 cells / lympho

Gm stain

AFB stain –neg

India ink/crag – neg

• Sulfadiazine and pyrimethamine/leucovorin

/antiepileptics

• Persistently irritable

CT chest- patchy infiltrate in post seg left lower lobe

CTA bd- normal

BAL – non contributory

He was started on second line anti-tb

Kanamycin ,etb,pza,,moxiflox,ethionamide,pas, clofazimine

D4T.3TC,EFV,TDF,FTC,ATV,RTV

• 1.NRTI+ PI

• 2.NRTI+PI+INTEGRASE INHIBITOR

• 3.PI+INTEGRASE INHIBITOR

• 4.PI+ NRTI+ INTEGRASE INHIBITOR

Darunavir/ritonavir/raltegravir

/lamivudine/zidovudine

• LFU ,admitted outside seizure

• Antiepileptics escalated

• Cd4 1/2/17-98(7%)

• 24/7/18- 66(7.6%)

• August – irritable

pain in right hand

visual complaints

lethargic

claims to be compliant

Wife

• Diagnosed 2008

• Delivered 2 girl child

• PI based regimen PPTCT - stopped

• Evaluation- asymptomatic

• Cd4-13/4/15- 171(17.4%)

• VL- 53606 copies

• Husband- 2nd line failure

Tdf/ftc/atazanavir,rit

onavir

Compliant

Cd4-753 copies /

VL-<20