Dr Sophia Davies. Birmingham Heartlands Hospital. 18 th Annual Conference of the British HIV Association (BHIVA)

Transcription

1 18 th Annual Conference of the British HIV Association (BHIVA) Dr Sophia Davies Birmingham Heartlands Hospital April 2012, The International Convention Centre, Birmingham

2 18 th Annual Conference of the British HIV Association (BHIVA) Dr Sophia Davies Birmingham Heartlands Hospital COMPETING INTEREST OF FINANCIAL VALUE > 1,000: Speaker Name Dr Sophia Davies: Statement None declared Date April April 2012, The International Convention Centre, Birmingham

3 A Soldier s Tale Virtual Clinic BHIVA Annual Conference 2012 Sophia Davies

4 History 51 year old heterosexual Caucasian man Engineer, ex-infantry Discharged 1991, postings to East Africa, Iraq 3cm abscess on chin (October) Dentist, two extractions Weight loss, fever and night sweats (December) Admitted to DGH with PUO, CRP 30, LDH 3170, Hb 8.2 g/dl CT scan looks like cancer Transferred to Birmingham Heartlands

5 Axial CT at level of L1 Soft tissue mass Superior Mesenteric Artery Peritoneal thickening Descending colon Left kidney

6 Coronal section Stomach Large homogenous mass SMV Peritoneal thickening Free fluid Urinary bladder

7 apoptotic cell two histiocytes ( footprint nuclei) small reactive lymphocyte

8 Tissue and bone marrow biopsy B-cell associated antigens: surface IgM, CD19, CD20, CD22 and CD79a as well as CD10, HLA- DR C-myc translocation by fluorescent in-situ hybridisation Burkitt s lymphoma

9 International Prognostic Index Good prognostic factors Poor prognostic factors Age 60 or below Age above 60 Stage I or II No lymphoma outside of lymph nodes, or lymphoma in only 1 area outside of lymph nodes PS: Able to function normally Serum LDH is normal Stage III or IV Lymphoma is in more than 1 organ of the body outside of lymph nodes PS: Needs a lot of help with daily activities Serum LDH is high IPI = 3

10 HIV test

11 HIV test +

12 What we know Renal function: normal Haemoglobin: 8.2 g/dl Eye review: no retinitis OI markers: all negative STS: negative Neurology all normal MRI brain normal

13 What we don t know Baseline viral load? CD4 count? Resistance genotype? HLA? Hepatitis status?

14 Question 1 -- would you: 1. Start treatment for lymphoma and commence ART only if CD4 < Commence ART and start lymphoma treatment once VL undetectable 3. Commence lymphoma treatment and then ART in two weeks 4. Commence lymphoma treatment and ART straight away 5. Other

15 1. Start treatment for lymphoma and commence ART only if CD4 < Commence ART and start lymphoma treatment once VL undetectable 3. Commence lymphoma treatment and then ART in two weeks 4. Commence lymphoma treatment and ART straight away 5. Other

16 Question 2 -- In the absence of baseline results, what ART would you start? 1. Truvada and Efavirenz 2. Kivexa and Atazanavir/ritonavir 3. Truvada and Raltegravir 4. Kivexa and Raltegravir 5. Truvada and Maraviroc 6. Truvada and Raltegravir and Maraviroc

17 Anti-retrovirals Truvada, Raltegravir and Maraviroc Truvada exchanged for Kivexa after HLA result available Resistance test: wild type Maraviroc discontinued

18 Question 3 -- which primary OI prophylaxis would you use? 1. Co-trimoxazole and Fluconazole and Aciclovir 2. Dapsone and Fluconazole and Aciclovir 3. Co-trimoxazole and Fluconazole and Aciclovir and Azithromycin 4. Co-trimoxazole and Posaconazole and Aciclovir and Azithromycin 5. Other

19 Interactions?

20 Question 4 -- what chemotherapy? 1. CHOP or R-CDE 2. CODOX-M/IVAC or Hyper CVAD 3. R-CODOX-M/IVAC 4. What the.?

21 R-CODOX-M/IVAC Rituximab Cyclophosphamide Vincristine Doxorubicin High-dose methotrexate Ifosfamide Etoposide High-dose cytarabine

22 Known interactions ATV EFV MVC RAL Cyclophosphamide Vincristine Doxorubicin Methotrexate???? Ifosfamide???? Cytarabine Etoposide

23 Known interactions ATV EFV MVC RAL Cyclophosphamide Vincristine Doxorubicin Methotrexate Ifosfamide Cytarabine Etoposide

24 Chemotherapy R-CODOX M/IVAC Rasburicase Cycle 1 Neutropenic sepsis Vomiting++

25 Progress Viral load at two weeks: 609 copies/ml Completed chemotherapy, full remission

26 Thanks to: John Watson Graham Collin Zbigniew Rudzki Steve Taylor