Clinical Case Scenario HIVeEducation Workshop, Sint Maarten 2009
Background Mrs. S is a 34 year-old woman who was referred from the VCT center after testing HIV positive three weeks ago. Her husband recently died from cryptococcal meningitis; during his hospitalization he tested positive for HIV, causing her to pursue testing.
Background, continued Mrs. S s past medical history is remarkable for an appendectomy performed at age 18. She has otherwise been well until her diagnosis for tuberculosis 4 months ago. At that time she began four-drug treatment for TB, and is currently taking isoniazid and ethambutol. HIV testing was recommended and refused at the time of TB diagnosis. Other than TB treatment, she is taking no medications.
Allergies She is allergic to trimethoprim/sulfamethoxazole (Bactrim) which causes a diffuse erythematous maculopapular rash.
Physical exam Her physical exam is notable for a thin, welldeveloped woman in no acute distress. HEENT exam reveals candida on the tongue and buccal mucosa. Heart, lung, and abdomen exam are normal.
Hemoglobin11.7 ALT39 White blood cell4.8 AST47 Neutrophils74% Lymphocytes20% Monocytes6% Platelets167,000 HIV+ Laboratory test
For this patient, what evidence (history, physical examination, and/or laboratory data) supports beginning antiretroviral therapy (ART)? Thrush; oral candida (candidiasis) Low total lymphocyte (lymphs) count (TLC); total TLC = 960; TLC, 1,200 Tuberculosis within past two years; recent tuberculosis HIV+ Social history: husband died of cryptococcal meningitis-likely more advanced disease, so wife likely has been infected for a while.
Do you identify any barriers to good ARV adherence? If so, what would you recommend to address the barrier's? Widowed; limited (or unknown) support system TB (tuberculosis) meds; concurrent TB treatment Finances; limited money Limited knowledge of HIV Not previously ill; good baseline health; no symptoms Potential childrearing responsibilities; potential pregnancy In favor of adherence she opted for testing when her husband was positive In favor of adherence by taking TB drugs she is demonstrating her capacity to take drugs over time The fact that she refused to go for testing The reaction to Septrin may make her hesitant to take more drugs
What antiretroviral medications would you initiate? AZT (Zidovudine) + 3TC + nevirapine (patient already has anemia which might be worsened by AZT) Stavudine (d4t), lamivudine (3TC) and Nevirapine) (lowest cost)
What antiretroviral medications would you initiate? Acceptable alternate regimens: AZT (Zidovudine) + 3TC + efavirenz (patient already has anemia which could be worsened by AZT) d4t (Stavudine) + 3TC + nevirapine more expensive than whats above and need to make sure she isn t pregnant or expecting to become pregnant d4t (Stavudine) + 3TC + efavirenz
What antiretroviral medications would you initiate? Not acceptable Less than three medications Medications which are not antiretrovirals
What toxicities could be associated with the antiretroviral medication s AZT Anemia Nail changes Macrocytosis Fatigue Nausea; GI disturbance Lactic acidosis Hepatic (liver) toxicity myopathy you chose?
What toxicities could be associated with the antiretroviral medication s you chose? 3TC Lactic acidosis Hepatic (liver) toxicity Nausea; GI disturbance Rash (rare)
What toxicities could be associated with the antiretroviral medication s you chose? d4t Nausea; GI disturbance Peripheral neuropathy Lipodystrophy Pancreatitis Lactic acidosis Hepatic (liver) toxicity
What toxicities could be associated with the antiretroviral medication s Efavirenz you chose? Nausea; GI disturbance Central nervous system (CNS) hyperactivity; abnormal dreams; hallucination Rash Hepatic (liver) toxicity Teratogenic (in monkeys)
What toxicities could be associated with the antiretroviral medication s you chose? Nevirapine Rash Nausea; GI disturbance Hepatic (liver) toxicity
Additional Information You and your patient decide to begin antiretroviral therapy. Ten days after starting therapy, she calls to report that she has developed a red, pruritic rash covering most of her trunk and extremities. She denies fever, myalgias, other constitutional symptoms, and says she feels well except for the rash.
Which antiretroviral medication(s) would be the most likely explanation for her symptoms? Best answer Nevirapine Acceptable answer Efavirenz
How would you manage the problem of her rash? Check LFTs (liver function tests) Treat with diphenhydramine (Benadryl) Treat with steroid cream Check hemoglobin and/or hematocrit Continue ART Observe for worsening (worse rash; fever, abdominal pain; mucosal involvement [oral rash, mouth lesions]) Make sure patient started nevirapine with only once daily-if not reduce dose to once daily and when rash resolves increase to twice daily