CASE DISCUSSIONS

Diagnosis and monitoring of HIV infection 1. Dr. X, a pediatrician started realizing that he was losing weight over 2 months. His patients also told this to him and he started fearing that he may be infected with HIV. He got a Western blot done without doing any screening test at a local laboratory with a proxy name. He had sent the sample after overnight refrigeration. It showed all HIV-1 bands positive and was reported as HIV-1 reactive. He was shocked by the report because he never had any high risk behavior. He also did not remember of any needle-injuries except frequent exposure of the intact skin with blood. He was 36 years old and had an episode of infarct and had undergone an angioplasty about a year ago. He repeated his Western Blot at another laboratory. This showed only p24 antigen band and was reported as indeterminate. He already started stocking antiretrovirals in anticipation of treatment. He has come to you for consultation. What advice will you give? 2. Mr. Y is a police inspector and had a history of high risk sexual exposure about a year ago. He wanted himself to get tested and was advised to get a rapid ELISA. It was reported non-reactive. He still wanted to be more sure hence repeated his ELISA thrice over a period of 1 month. All were non-reactive. He wanted to be more sure and asked his doctor what test he should do. He was advised to get a Western Blot which also was reported non-reactive. He still was not satisfied and was advised a plasma viral load test. It was reported as 750 copies/ml. He gets panicky and contemplates suicide. However comes to you for a last opinion. What opinion would you give him? 3. Mr. Z is a hemophiliac and known HIV-1 reactive since six years. He had an episode of Tuberculous pleural effusion and completed his course of ATT. He got his CD4 counts and viral load done from a laboratory in Mumbai. His CD4 count reported was 310/mm3 and PVL was < 50 copies/ml. His physician started him on HAART (d4T/3TC/SQV-SGF) and repeated his tests after 1 month, again from the same lab. This time it was reported as 543/mm 3 and 120,340 copies/ml. He has come to you for a second opinion. What will you advise him?

BIOSAFETY AND POST EXPOSURE PROPHYLAXIS 1. Dr. X, a surgeon gave a frantic call to you. He was operating for a hernia about 2 days ago and had a needle stick injury while closing the wound. He washed his hands with soap and water and applied lot of spirit on it. He had forgotten about the whole episode until yesterday when the patients HIV test was reported reactive. He wants advice on what to do now. What will you advise him? 2. Dr. Y is a gynecologist. While delivering a HIV positive mother she had accidental splash of amniotic fluid on to her eyes. She immediately calls you. What is your advice? 3. Mr. Z is a lab technician. He finds extremely uncomfortable to use gloves during venepuncture. After withdrawing blood from an HIV patient he attempted recapping the disposable needle during which he got a needle stick injury. He immediately called a physician who advised him to start AZT/3TC/NVP. He started developing severe headache, nausea and abdominal pain after 2 days on drugs. He visits you for an opinion. What is your advice? 4. Mr. A is a foreign national, member of an international spiritual organization in Pune. He had an unprotected sexual exposure with an Israeli friend the previous night. She tells him later that she is HIV positive and already taking antiviral drugs since 1 year. Mr. A gets panicky and asks for your opinion. Please advice him.

Primary infection (Summarize immuno-pathogenesis of HIV) 1. MSD is a 55 year old gentleman residing at Nandurbar. He is a known case of hypothyroidism and on regular supplementation. On 14/9/2002 he developed an acute MI when he was thrombolysed and treated with standard protocol. Subsequent angiography revealed triple vessel disease and a CABG was done for him on 30/09/2002 at Hyderabad. A routine pre-surgery rapid ELISA (Tridot) was reported negative. On the day of surgery patient was transfused 5 pints of whole blood (3 from blood bank and 2 fresh donors). The patient or relatives are unaware about the HIV status of the transfused blood, but it is assumed that blood must have been screened prior to transfusion since it was a reputed hospital. Patients post operative course was uneventful. He went back to his home town and started developing cough and breathlessness on 16/10/2002. He was admitted to this hospital by cardiologist for cardiac evaluation. On 23/10/2002 a routine ELISA was done was reported positive. Subsequently a Western Blot was done which revealed strong p24, gp120, gp160 bands and faint bands of gp41, p55 and p56. It was reported as positive. Patient was counseled about his HIV status. He had no history/evidence of fever, rash and sore throat. His CD4 count done on 26/10/2002 was reported as 123/mm3 and plasma viral load by Roche Amplicor RT PCR was 4,57,300 copies/ml (5.66 log). He was willing to go ahead with therapy and was initiated on AZT/3TC/EFV. 2. Mr and Mrs ABC have been married for 7 years, when he was found HIV reactive. He had a baseline CD4 count of 458/mm3 and no specific treatment was offered. They were counseled about safer sex practices. After 13 months Mrs ABC reported to the clinic with fever and myalgia for 3 days. History revealed repeated unprotected sexual exposures with her husband over previous months. She was prescribed some antipyretics and was advised to get an ELISA done. Her ELISA was reported negative but Western Blot revealed strong env bands and was reported indeterminate. A Western Blot was repeated after 6 weeks and revealed all bands reported as positive. A CD4 count done at that time was 218/mm3. She could not afford viral load.

Immune-restoration disorders 1. Mrs NBS, a school teacher, aged 33 years was diagnosed with HIV infection on 25/5/2002. She had a history of transfusion 8 years ago and her husband is also positive. Her presenting symptoms were anorexia, weight loss, low grade fever and pruritus for 1 month. Weight loss was 10 kgs in 6-7 months. There was no other significant history. A routine laboratory evaluation and a Chest Xray and USG abdomen was normal. On 3/6/2002 her CD4 report was 12/mm3 with a percentage of 2%. She was started on d4T/3TC/NVP (4/6/2002). After 6 days of initiation of treatment she started complaining of vomiting, nausea, fever and abdominal pain. Her LFTs done on 17/6/2002 were as follows: AST-75, ALT-86, T Bili-0.6, ALK PO4-486. The drugs were discontinued with nevirapine first followed by d4T/3TC after 3 days. Her symptoms worsened and she came back after 1 month. Her LFTs on 15/7/2002 were as follows: AST-407, ALT-216, T Bili- 0.5, ALK PO4-1271. A USG abdomen done at that time revealed bright liver echopattern with edematous gall bladder wall. She was admitted for supportive therapy. She improved clinically however LFTs repeated subsequently were as follows: 18/7/2002 26/7/2002 AST 713 448 ALT 561 401 Tbili 2.2 6.2 Dbili 1.6 4.3 ALKPO4 1250 1868 How will you evaluate further? 2. SAD, 30 year male was diagnosed HIV positive on 6/2/2002. He presented with headache over 2 weeks and a CT brain showed an enhancing ring lesion with massive edema in left basal ganglia. His Serum Toxo IgG and Cryptococcal antigen were positive and negative respectively. His CD4 count was 12/mm3. He was initiated on Pyri/Sulpha/folinic acid combination and he improved clinically over two weeks. A repeat scan done on 20/3/2002 showed complete resolution of the lesion. He was initiated on d4T/3TC/NVP on 13/4/2002. After 3 weeks he started complaining of severe headache and vomiting. His sensorium deteriorated rapidly and needed hospitalization. On examination he had irrelevant speech, no evidence of any focal neurological deficit with mild neck stiffness. A serum cryptococcal antigen was positive, while CT brain was normal. A lumbar puncture was done which had protein/sugar normal with 45 cells, all lymphocytes. Gram and AFB staining were negative and India ink demonstrated cryptococci. He was initiated on Amphotericin B and gradually improved over the next 2 weeks. He was discharged on antiretrovirals and fluconazole, pyri/sulpha/folinic acid. He did well on therapy and a subsequent CD4 repeated on 20/7/2002 was 229/ mm3.

What is the pathophysiology? Will you discontinue fluconazole/anti-toxo prophylaxis?

Switching therapies and managing failure 1. Maj. RJP, 32 years is a commando with the army, was diagnosed HIV positive in April 1997 as part of routine yearly check up in the army. He was asymptomatic and had no significant past medical history. His CD4 count on 25/4/1997 was 253/mm3 with a PVL by bDNA of 4061/ml (from Mumbai). Patient was insisting for therapy and hence was initiated on AZT/3TC/IDV. Initially for a period of 3-4 months he found it difficult to get adjusted to the regime, particularly with taking IDV on empty stomach. He is still following up and is doing clinically fine. Following are his sequential reports: 6/97 CD4 PVL 298 2616 10/97 1/98 269 3800 547 <50 5/98 ND <50 10/00 11/02 ND <50 979 <50

His lipid profile and sugars done on 11/02 were normal. Can you switch him to AZT/3TC/EFV? He was switched to AZT/3TC/EFV from 11/02. He took drugs regularly. 5/03 11/03 CD4 980 1254 PVL 862 114 His lipid profile done on July 2003 showed TC-245, TG-743, HDL-36, LDL-62, Ratio-6.8 at his hospital. He was put on . His repeat lipid profile was done on 12/03 showed TC-175, HDL-43, TG-475, LDL-62. Should you change him to AZT/3TC/NVP?

2.

Mr RSR, 23 years carpenter from Rajasthan was diagnosed HIV positive in May 2001. He had history of tuberculous effusion in 1998 for which he took 6 months of ATT. His baseline CD4 count was 120/mm3. His physician started him on AZT/3TC. He felt better and was following up regularly. His CD4 on 1/02 and 7/02 were 146/mm3 and 90/mm3 respectively. His physician added NVP to AZT/3TC and a repeat CD4 in 11/02 was 30/mm 3. He has now been referred to you. How will you evaluate and manage him?

3. SMS, female aged 37 years was diagnosed HIV-1 positive in Dec 2000. She was asymptomatic at baseline and had history of herpes zoster in May 1998. Her baseline CD4 count was 390/mm3. She was initiated on AZT/3TC/NVP by her physician. Her follow up CD4 counts were 666/mm3, 540/mm3 and 740/mm3 at 6, 12 and 18 months respectively. She has developed facial atrophy and increased breast size and she wants to discontinue treatment. What is your advise?

ART and pregnancy 1. Dr.AVM is a general practitioner and HIV-1 positive since 1997. Her husband is HIV negative. She had herpes zoster and Pulmonary tuberculosis in 1997 and completed 6 months of ATT. Her CD4 at baseline was 290/mm3. She got pregnant in 1998 and took AZT for the last 4 weeks. In 2000 she repeated her CD4 count, which was 78/mm3. She was started on d4T/3TC/NVP and is doing clinically well. Her last CD4 count in June 2002 was 572/mm3. She wants to conceive and has come to you for your opinion. What is your advice? 2. Mrs. DBM, 32 years conceived after 10 years of marriage. Both she and her husband are HIV positive since 1998. Her husband is on d4T/3TC/NVP and is doing clinically and immunologically well. A CD4 count done at the end of first trimester is reported as 120/mm3. What is the treatment you would like to offer to her? She develops eclampsia and baby was delivered by C-Section at 34 weeks. The birth weight is 1.2 kgs, APGAR score at birth is good. Her neonatologist wants to know what regimen can be given to the baby and how long they can defer starting it? 3. Mr. and Mrs. XYZ have been diagnosed HIV positive in 1999. Mr. XYZ was started on AZT/3TC/NVP in 2001, but he was taking the drugs irregularly. His CD4 count was 134/mm3, 180/mm3, and 98/mm3 at baseline, after 6 months and 1 year of therapy respectively. His wife conceived in July 2002 and wants to continue pregnancy, since this was their first child. What is your advice?

Managing OIs (presentation on HIV and TB) 1. RMB, 45 year old doctor had long standing fever with weight loss since 9 months. All investigations to diagnose cause of fever were negative. He was put on empirical ATT for 9 months but was not improving. He was detected HIV-1 positive on 25/9/2002. His CD4 count done from Mumbai was 196/mm3. He came to us for a second opinion. His weight was 55 kgs with no other significant clinical findings. His USG abdomen, Xray Chest PA, LFTs were normal. His hemoglobin was 8.2 g%. All other hemogram parameters were normal. His 24 hour urinary AFB was negative. How will you evaluate him? 2. ABC, 23 year old female presented with fever and weight loss since 6 months. On evaluation she had pallor, was cachexic (weight-35 kgs) and with no external lymphadenopathy. Her Hemoglobin was 8.3 g%, normocytic normochromic and platelets of 54,000/mm3. Her Xray chest was normal. How will you evaluate this patient further?

HIV-associated nephropathy 1. DYG, 35 year old male, presented with swelling of both lower limbs and puffiness of face since 2 months. He had no history of oliguria. He also complained of breathlessness worsening on exertion. He had history of jaundice 2 years ago, self limiting. He is a chronic alcoholic since 8 years. On examination his weight was 76 kgs., he had bilateral pedal edema and facial puffiness. He did not have any ascites. His Xray chest and hemogram were normal. Urine routine showed protein 4+ and few granular casts. His USG abdomen showed normal sized kidneys with mildly raised cortical echogenicity suggestive of parenchymal disease, with minimal free fluid and a normal liver. His BUL was 30, Creat-0.8, electrolytes, LFTs was normal. 24 hour urinary protein was 12.9 g. A renal biopsy revealed hyperemic glomeruli, hypercellualrity with inconspicuous Bowmans space, occasional glomeruli showing presence of adhesions. Tubules showed moderate cloudy change, while some tubules showed pink staining proteinaceous casts. Interstitium showed focal lymphocytic collection. This picture was suggestive of proliferative glomerulonephritis (slide shown). His CD4 count was 589/ mm3. Lipid profile was as follows S.cholesteraol-306, LDL-239 with increased Cholesterol/LDL-7.9. What will be your approach to management?

CMV disease in HIV 1. SM, 35 year old male presented with generalized weakness, anorexia, and fever and weight loss for over 2 months. He was diagnosed HIV positive on 17/07/2002. He had a history of herpes zoster 12 years ago. On examination his weight was 45 kgs. with no other significant clinical findings. His routine investigations were normal except for an sonography of abdomen which revealed multiple pre and para aortic glands with microabscesses in the spleen. He was started on HRZE and he improved with the same. His CD4 count was 29/mm 3. In November he started complaining of breathlessness increasing on exertion, fatigue and generalized weakness. On examination he had tachycardia and an S3 gallop. His BP was 90/70mm. His chest x-ray revealed cardiomegaly with prominent bronchovascular markings. A color Doppler revealed the following - Dilated all four chambers - Akinetic anteroseptal area. - Depressed LV function LVEF-25% - Advanced diastolic dysfunction (restrictive) - Grade II/IV MR and TR - Mild PH Findings were suggestive of dilated Cardiomyopathy. His fundus evauation showed few scattered soft exudates in left eye and exudates and hemorrhages in the right eye. What is your diagnosis and how will you evaluate and manage further.

Neuro-AIDS 1. SRP, 35 year old male was diagnosed with HIV infection 3 years back. He had herpes zoster at that time. His last CD4 count done about 3 months ago was 96/mm3. He was put on TMP-SMX but he could not afford anti-retroviral therapy. He was brought to the casualty with history of two episodes of seizures, focal onset with secondary generalization. On examination he was hemodynamically stable, afebrile with mild pallor. He had extensive oral candidiasis. CNS examination revealed normal sensorium with no evidence of focal neurological deficit. Other systems were unremarkable. He was given phenytoin IV, loading followed by maintenance dose. He gave history of not taking any of his drugs for last 2 months. How will you further evaluate this patient? 2. MRS, 27 year old female presented with severe headache and vomiting for the last two weeks. She initially took some analgesics but did not improve. She was diagnosed HIV positive about 4 months ago, when her husband died due to AIDS. Her CD4 at that time was 19/mm3. She was put on TMP-SMX daily, Azithroycin weekly prophylaxis. She could not afford ART. On examination she had mild fever, oral candidiasis and pallor. On CNS evaluation she did not have any evidence of focal neurological deficit. There was no neck stiffness and kernings sign was negative. She had no papilloedema. Her serum cryptococcal antigen was positive. A CSF examination revealed normal proteins and sugar and mild lymphocytic pleocytosis. Gram and ZN staining were negative. How will you manage her further?