Case Study

Cloete van VuurenID Physician

50 year old male

• Abscess over L parotid gland• Cryptoccal meningitis 2010• PTB 2010 – completed 6/12 of Rx• Stopped TDF/FTC/Efv 1 year ago

• Pus aspirated – ZN pos, GeneXpert Rif Resistant

4

• Sputum culture – Rif, INH resistant – Aminoglycoside and Moxifloxacin sensitive

• Initiated onAmikacinMoxifloxacinTeridizoneEthionamidePZA

ART

• 50 year old male• Weight 33 kg• CD4 = 49• sCreat = 70• Hemoglobin = 6.4• Calculated Creat clearance = 48.9• Unable to walk

Which ART Regime do you initiate this patient on?

1. Tenofovir/Emtricabine/Efavirenz2. Zidovudine/lamivudine/Efavirenz3. Stavudine/Lamivudine/Efavirenz4. 2NRTI + Nevirapine5. 2 NRTI + Aluvia

Delirium

Delirium?

1. Chronically ill and debilitated2. Alcohol withdrawal3. Secondary infection4. Medication5. Other

Which one of the following drugs is the most likely cause of his delirium?

1. Efavirenz2. Moxifloxacin3. Teridizone4. Pyrazinamide5. Ethionamide

Desperately trying to sort out his delirium:

• Biochemically normal• No other infection identified• Switched to Nevirapine• Stop all TB drugs• Haloperidol

Which side effects should be routinely monitored during the injection phase?

1. Renal function2. Hearing test3. Thyroid function4. Liver function5. Fullblood count

Delirium

DVT

Is DVT’s associated with Tuberculosis or TB Rx?

1. Yes2. No

Series1

0

2

4

6

8

10

INRWarfarin

Month 3 on MDR TB Rx:

• Due to his delirium it is impossible to do a hearing test

• Creatinine – 150• Hemoglobin increased to 10 g/dl• Sputum culture negative

His Creatinine rises to 230 – will you stop the Amikacin?

1. Yes 2. No

Month 6

• Can sit out – walk short distances• Gaining weight 31kg – 45 kg• More orientated• Monthly sputum TB cultures negative• Efavirenz – no effect on delirium

“BILATERAL SYMETRICAL HGH FREQ SNHL SEVERE TO PROFOUND (HEARING AID NEEDED)BUT HE DOESN’T WANT A HEARING AID.”

Discharge

• Will come to work daily – only “non-strenous”work• Will DOT at ward

• Does not come regularly for medication• Often smells of alcohol• Family?• Social worker involved

Virological failure?

1. Switch to AZT/3TC/Aluvia2. Request Genotype3. Tenofovir/3TC/Aluvia4. Other

Adherence intervention

• DOT ART in the morning with MDRTB treatment

K103N, M184V

K103N, M184V

• Disappeared for a month

Why is this patient not taking his treatment?

1. Treatment illiteracy2. Social circumstances3. Poor support4. Mood disorders5. Alcohol abuse

• HIV Dementia

Conclusion

• Social circumstances• Alcohol• Delirium• DVT• HIV Dementia• TB/MDR TB vs HIV• “Human Nature”

Case 2

1. When did you initiate your first patient on ART?

1. <20042. 2004- 20073. 2008-200104. 2010 – 20155. None

Depression

PN

MI

Cholesterol

In-stent thrombosis

Aug10 Sep 11 Feb 12 Oct 13

Total Cholestero

l (mmol/l)

5.7 4.5 4.5 11.1

Trig (mmol/l)

56

HbA1C 11.5%

Aug10

Sep 11 Feb 12 Oct 13 Mar14 Apr 15

TotalCholesterol

(mmol/l)

5.7 4.5 4.5 11.1 6.0 8.5

Trig (mmol/l)

56 19 32

HbA1C 11.5% 6.7% 7.3%

Aug10 Sep11 Feb12 Oct 13 Mar14 Apr 15 Oct 15

Total Cholesterol

(mmol/l)

5.7 4.5 4.5 11.1 6.0 8.5 4.6

Trig (mmol/l)

56 19 32 1.2

HbA1C 11.5% 6.7% 7.3%

Case 3

In your experience, what is the most common reason for failing 2nd line ART?1. Not taking treatment2. Not absorbing3. Side effects4. Mood disorders5. Substance abuse

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Is she taking her treatment?

1. Yes2. No

M41L D67N V75IM M184V L210W T215Y A98G V106I Y188L

RHZE

What will you do?

1. Continue as is2. Tdf/FTC/Raltegravir3. Tdf/FTC/Raltegravir/Darunavir/r4. Other

Conclusion

• Take nothing for granted• (Double check everything and everybody)