Case Study: TB-HIV co-infection

Transcription

1 Case Study: TB-HIV co-infection Sarah Dietz, BSW Linkage to Care Specialist AIDS Resource Center of Wisconsin Julia Greenleaf, RN, MPH Public Health Nurse Public Health Madison & Dane County

2 The speakers have no financial or other conflicts of interest to report.

3 Learning objectives Characterize the impact of TB and HIV co-infection on the lived experience of one immigrant to the USA Understand how community agencies collaborate in the management of complex health conditions

4 33 year-old female from Liberia Arrived USA December year old son stayed in Liberia Seeking asylum Symptoms April 2016 Hospitalized June 2016

5 Hospitalized 6/28/16 6/28 CXR Hilar adenopathy 6/29 QFT + 6/29 Chest CT: miliary pattern 7/1 & 7/7 lymph node biopsies; AFB smear+ No known TB exposure Incidence of TB in Liberia 308/100,000 (USA = 3.2) Reference: WHO, 2015

6 Miliary TB Characterized by large amounts of TB bacilli, with seeding of bacilli in the lungs & hemotogenous spread throughout the body

7 6/30/16 HIV reactive Viral load: 720,000 [Goal range: Under 200, but <20 or undetectable preferred] CD4 = 22 [Normal range: ] No other apparent opportunistic infections Exposure unknown Incidence in Liberia: TB-HIV = 40 (USA =.18) WHO, : 10.4 million new cases active TB globally, with 11% coinfected

8 Medical plan: Continue isolation RIPE daily x 2 wks before starting HAART initiated 7/13 Prophylactic Bactrim (PCP & toxoplasmosis) & azithromycin (MAC) DC home after 3 weeks Challenges: No cough no sputums Lymph node biopsy processing Nausea & low-grade fevers Anticipating IRIS Immigrant status confers no health insurance Transportation, food, housing, living expenses

9 Client Focused Approach: Self: Client Addressing Challenges: Patience Family/Culture: Living situation, from Liberia in the US Living with family, in contact with people in Liberia Community/Environment: Madison Area, working with immigration, church Difficult to engaged due to illness, but attends church Collaboration: Public Health, UW, and ARCW ABC for health insurance, Incentives through PH, transportation from ARCW,

10 After one week home: I feel terrible Next evening text messages 5:30pm 10:30pm Fever uncontrolled by Naproxen & reaches F ER Re-hospitalized What s going on?

11 Immune Reconstitution Inflammation Syndrome (IRIS) Body becomes flooded with white cells proinflammatory cytokine cascade followed by reinforcements And body may respond to dead TB with inflammatory effect This is good (appropriately fighting opportunistic infections) & bad (inflammation, fever, tissue damage) Occurs in about 20% starting HAART; usually spontaneous recovery

12 Fortunately, IRIS seemed to be pretty short-lived Fever controlled & client home after 5 days IBP prn at home Continue RIPE Tentatively transfer care to ARCW Med changes: d/c rifampin, atripla, & bactrim; start rifabutin, truvada, & tivicay Complete initiation phase Moving forward: Viral load CD4 Immigration 1 st & 2 nd round of contacts all negative

13 Unexpected set-backs INH resistance Discordant drug susceptibility tests MGIT: PZA resistance MDDR: no indication of mutation that confers PZA resistance Culture-based DSTs likely low PZA resistance Mayo consult and med changes: Rifabutin, ETH, moxifloxacin then levofloxacin Side effects: PN

14 1-year old son living with relatives in Liberia Roughly 1/3 chance of HIV transmission happened in the following 3 ways: Exposure during in utero, during birth, and/or breastfeeding. 30x increased risk of TB transmission to infant when mother is HIV+ [Mukadi Y et al, AIDS 1997] Transplacental spread through the umbilical vein to the fetal liver Aspiration or ingestion of infected amniotic fluid Airborne inoculation from close contacts (family members or nursery personnel) Postpartum breastfeeding

15 1-year old son In apparent good health aside from brief respiratory illness in October contact with Liberian public health who confirmed ability to test Delay in contact information from client Lack of response from Liberia once referral sent (Sept 2016) WI State TB Program request for testing Test results 11/29/16

16 Barriers to Care Weakness HIV - IRIS/TB Resistance Son s recent dual diagnosis Difficult living situation Lack of Transportation Strengths Dedicated to Medication Adherence Supportive family caring for son in Liberia Support from outside friends (able to travel to see them) LTCS able to transport, learn bus route

17 Ongoing challenges: Appropriate treatment Minimizing drug side effects; current weight loss Immigration status Employment and healthcare benefits Permanent Housing Goal of getting son to US Medical updates on son can be minimal at times

18 Questions? Thank you!