Case 11.


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2006 Ophthalmology OPD
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Case 11 71 year-old white male From the UK Had lived in London Retried to South Coast town Ex-smoker EtOH - 8 units day wine/spirits Unmarried, lived alone

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Case 11: June 2006 Admitted by means of Ophthalmology with: Probable HIV-related fringe neuropathy Probable Pneumocystis jirovecii pneumonia CMV retinitis Sexual history: Friend – long haul male accomplice no UPAI 15 years Initial examinations: BAL: affirmed PCP CD4 7; VL 200,000

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Case 11 : PMH 2000 Seen in Hematology for continuing lymphopenia 2000 Admitted with weight reduction, watery loose bowels 2001 Admitted with cerebellar infarct 2001 Seen in Neurology OPD (3 in London, 1 somewhere else) for fringe neuropathy - obscure cause 2003 Admitted with weight reduction, OGD: oesophaghitis 2004 Admitted with cracked right neck of femur lymphocytes 0.5 (1.3-3.5) different mouth ulcers candida on mouth swab 2005 "Recurrent LRTIs" all through 2005

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Case 11 : June 2006 Seen in Ophthalmology OPD: vitreous separation in left eye 2/12 history of intense onset one-sided overcast vision OE: retinal rot highlights normal for CMV retinitis SOB Refractory to anti-microbials from GP Admitted to healing facility

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Case 11 : June 2006 Management: Left vitrectomy and intraocular foscarnet D/w Genitourinary Medicine group: "What is the ebb and flow treatment for non-HIV-related CMV retinitis?" GUM group: "Would this be able to be HIV-related?" Investigations: Rapid strip HIV test receptive Confirmatory fourth era HIV test positive

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Case 11 : June 2006 Further administration: CMV retinitis Intraocular foscarnet Initiated on Valgancyclovir 900mg po bd 21/7 →maintenance PCP treated exactly with Co-trimoxazole, measurement 120mg/kg bd 21/7 →prophylaxis HIV-related neuropathy Prednisolone 60mg po od Antiretroviral treatment started

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Case 11 : June 2006 1 day preceding arranged release: Septicaemic stun Died regardless of: overwhelming liquid revival expansive range anti-toxin spread ITU affirmation ventilatory backing maximal inotropic bolster Blood societies developed Klebsiella terrigena Cause of death 1a: gram negative sepsis 1b: multi organ disappointment 1c: immunosupression 2 °HIV

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Case 11 : synopsis 2000 Haematology OPD, holding on lymphopenia 2000 Gen. med. affirmation, watery looseness of the bowels, weight reduction 2001 General medicinal confirmation, cerebellar infarct 2001 Neurology OPD, fringe neuropathy - obscure cause 2003 Gen. med. confirmation, weight reduction - OGD: oesophagitis 2004 Fracture NOF, low lymphocytes, oral candida -recorded in ED notes "lives with male accomplice" 2005 General therapeutic affirmation, LRTI – low lymphocytes 2006 Ophthalmology OPD "non-HIV related CMV retinitis" 2006 HIV analyzed: PCP: CD4 7: VL 200,000

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Q: At which of his social insurance associations could HIV testing have been embraced? When he was seen with relentless lymphopenia? (2000) When he was conceded with watery looseness of the bowels? (2000) When he was conceded with cerebellar infarct? (2001) When he was seen for fringe neuropathy? (2001) When he was conceded with weight reduction and oesophagitis? (2003) When he was conceded with a crack and uncovered living with male accomplice? (2004) When he was conceded with intermittent LRTI? (2005) When he was seen for "non-HIV-related CMV retinitis"? (2006)

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Who can test?

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Who to test?

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Rates of HIV-contaminated persons getting to HIV care by territory of home, 2007 Source: Health Protection Agency, www.hpa.org.uk

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Who to test?

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Who to test?

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Who to test?

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8 missed open doors – 5 in ED - to analyze HIV before terminal presentation! In the event that present rules utilized, HIV could have been analyzed 6 years before 2000 Haematology OPD, enduring lymphopenia 2000 Gen. med. affirmation, watery looseness of the bowels, weight reduction 2001 General therapeutic confirmation, cerebellar infarct 2001 Neurology OPD, fringe neuropathy - obscure cause 2003 Gen. med. affirmation, weight reduction - OGD: oesophagitis 2004 Fracture NOF, low lymphocytes, oral candida -recorded in ED notes "lives with male accomplice" 2005 General therapeutic confirmation, LRTI – low lymphocytes 2006 Ophthalmology OPD "non-HIV related CMV retinitis " 2006 HIV analyzed: PCP : CD4 7: VL 200,000

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Learning Points This patient had various examinations and 5 affirmations more than 6 years, bringing about him much misery and costing the NHS a huge number of pounds Some patients won\'t not uncover hazard elements for HIV on routine addressing in Outpatients regardless of the possibility that the right inquiries are solicited Because from this the generally great medicinal groups taking care of him didn\'t consider HIV notwithstanding when the analysis appears glaringly evident with insight into the past An apparent absence of danger ought not deflect you from offering a test when clinically demonstrated

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Key messages Antiretroviral treatment (ART) has changed treatment of HIV contamination The advantages of early finding of HIV are all around perceived - not offering HIV testing speaks to a missed open door UK rules suggest all inclusive HIV testing for patients from gatherings at higher danger of HIV disease UK rules prescribe screening for HIV in grown-up populaces where undiscovered predominance is >1/1000 as it has been appeared to be financially savvy HIV screening ought to end up a standard test on presentation of lymphopenia, PUO, perpetual loose bowels and weight reduction of generally obscure cause

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Also contains UK National Guidelines for HIV Testing 2008 from BASHH/BHIVA/BIS Available from: enquiries@medfash.bma.org.uk or 020 7383 6345

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