“ADVANCED CLINICAL CARE CASE...

VERSION 1: MARCH 2018

“ADVANCED CLINICAL CARE CASE STUDIES”

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DISCLAIMER

The development of the Advanced Clinical Care Case Studies was made possible by the support of the

American People through the Centres for Disease Control and Prevention (CDC) under the CDC

Grant # 5U2GGH001143.

As our disclaimer, the contents of this report are the responsibility of Beyond Zero and do not necessarily

reflect the views of the CDC or the United States Government.

ACKNOWLEDGEMENTS

Beyond Zero is grateful for the commitment of CHAMP doctors

and CHAMP nurses who submitted notable cases to share

with their peers towards improved quality of care of our patients.

We would like to acknowledge the entire Beyond Zero ACC team for devoting time on the project.

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Clinical and System Case Studies Case Title 1. Space Occupying lesion (Nocardia abcess) in brain after

switching to 2nd line following virological failure to 1st line

Case source Referral Hotline

Case description 43 year old male with a CD count of 52 recently changed to a

lopinavir/ritonavir based regimen presented to the hospital in

Somerset East with a history of a swelling in the back as well

as a history of recent onset seizures. The patient was referred

to the ID clinic at Livingstone hospital for further management.

Case outcome · CT brain confirmed the presence of a space occupying

lesion in the brain

· US abdomen confirmed a para-spinal and psoas abscess

· Culture revealed Nocardia

· He was started on high dose cotrimoxazole and sodium

valproate

Prognosis Patient had a good recovery from the nocardia and the

seizures are now well controlled and the viral load is

suppressed.

Impact/Lessons learnt

(1 or more)

· Improved quality of life, seizure free

Nocardiosis is an acute, subacute, or chronic infectious disease that occurs in cutaneous,

pulmonary, and disseminated forms. Primary cutaneous nocardiosis manifests as

cutaneous infection (cellulitis or abscess), lymphocutaneous infection (sporotrichoid

nocardiosis), or subcutaneous infection (actinomycetoma).

Causes

Pulmonary and disseminated nocardiosis are clearly associated with immunocompromising

conditions, with approximately 60% of cases of nocardiosis other than mycetoma occurring

in individuals with some compromise of host defense systems.

Differentials: · Bacteria: Tuberculosis; Nocardiosis, Listeriosis · Fungi: Aspergillosis, Cryptococcosis, Mucormycosis · Parasites: Toxoplasmosis, Cysticercosis

Labs: The diagnosis of nocardiosis is established with culture of the causative organism from the infection site(s). All patients with nocardiosis, except those with mycetoma, should undergo brain imaging with either CT scanning or MRI (likely preferred). Intracranial abscess is the most common abnormality found. Treatment: Although not convincingly demonstrated superior, trimethoprim-

sulfamethoxazole (TMP-SMZ) is considered the therapy of choice by most authorities.

Divided doses of 5-10 mg/kg/d of the trimethoprim component should be administered to

produce sulfonamide levels of 100-150 mcg/mL; such levels should possibly be confirmed

in individuals with severe disease.

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Case Title 2. Cryptoccocosis

Case source LVH CHAMP site

Case description 45 year old male with a CD4 count of 17 having previously

defaulted. Referred to the skin clinic with a history of a

disseminated rash. His case was complicated by multiple

psychosocial issues.

Case outcome He was diagnosed with disseminated Cryptococci with

complicating meningitis and choroiditis. He was started on

amphotericin B and fluconazole, which was complicated by

renal impairment, refractory high intracranial pressure which

eventually resolved, followed by a delayed cryptococcal IRIS

with persistently high pressures requiring frequent lumbar

punctures.

He was referred to the psychologist.

Prognosis He has made a good recovery and now has a suppressed viral

load.

Impact/Lessons learnt

(1 or more)

His psychosocial issues have been resolved and his family has

been restored.

Decreased HIV transmission

Infection with the encapsulated yeast Cryptococcus neoformans can result in harmless

colonization of the airways, but it can also lead to meningitis or disseminated disease,

especially in persons with defective cell-mediated immunity. Cryptococcosis represents a

major life-threatening fungal infection in patients with severe HIV infection.

Signs and symptoms

The presentation in cryptococcosis varies with the site of infection and the patient’s immune

status.

1. HIV-infected patients with pulmonary cryptococcosis may present with the following:

Fever (84%), Cough (63%), Dyspnea (50%), Headache (41%)

2. Meningitis and meningoencephalitis, the most common manifestations of CNS

cryptococcosis, are usually subacute or chronic in nature.

Headache, Confusion, Fever, Blurred vision, Photophobia, Seizures

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After lung and CNS infection, the next most commonly involved organs in disseminated

cryptococcosis include the skin, the prostate, and the medullary cavity of bones.

3. Cutaneous manifestations (10-15% of cases) are as follows:

Papules, pustules, nodules, ulcers, or draining sinuses, umbilicated papules

Diagnosis

o Cutaneous lesions: Biopsy with fungal stains and cultures

o Blood: Fungal culture, cryptococcal serology, and cryptococcal antigen testing

o Cerebrospinal fluid: India ink smear, fungal culture, and cryptococcal antigen

testing

o Urine and sputum cultures, even if renal or pulmonary disease is not clinically

evident

o In HIV patients with cryptococcal pneumonia, culture of bronchoalveolar lavage

washings

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Case Title 3. Querry TB Lymphadenitis/malignancy

Case source CHAMP Referral Hotline

Case description 22 Years old female patient initiated on HAART in may 2017

co-infected with TB which was diagnosed by x-rays

completed treatment on the 17/10/2017 presents with a

growth on the neck which started as a gland but grew larger

and also oozing pus.

Booked at LVH champ 13/11/2017

Case management • Client seen and examined by Doctor (13/11/2017)

• ? TB cold abscess

• Differential Diagnosis: 1.Prolonged IRIS 2.Rule out

malignancy 3.Resistant TB strain

• Investigations: FNA (NECROTISING suppurative

lymphadematis), VL, GXP/culture

• SECOND visit(13/12/2017): review results – fna

auramine negative, gxp negative, tb culture pending,

vl 73

• Tcb in 1month

Prognosis N/A

Impact/Lessons learnt · Investigate enlarging masses early

TB is considered as the most usual opportunistic infection in belts where HIV infection is

rampant. The focus organ of mycobacterium TB is bronchopulmonary apparatus, and those

in the head and neck region are commonly secondary. Primary involvement is prevalent in

youngsters and adolescents than in grown-ups

Presentation:

· Primary orofacial TB customarily comprises the gingival, mucobuccal folds and

inflammatory foci neighboring to the extraction sitesor teeth.

· Secondary oral TB can arise at any age but is most usual in mid and older age

persons. It emerges from a mended primary focus or owing to endogenous

extension of the infection.

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· Secondary TB is mostly persistent in nature and can begin significant damage

to the tangled tissue with caseation, fibrosis and cavity formation

· Orofacial lesions may show various presentations such as nodules, fissures,

ulcers or granulomas.

· When evaluating such cases, clinicians should consider both infectious

processes, such as primary syphilis, fungal diseases, and non-infectious

processes such as chronic traumatic ulcer and squamous cell carcinoma.

Diagnosis:

If there is no systemic attachment, an excisional biopsy is suggested to determine a

complete diagnosis.

Treatment:

The basic principles for the treatment of pulmonary TB apply to extra-pulmonary TB as well.

For TB at any site, a 6-9 months course of treatment regimen that include INH and RIF is

recommended

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Case Title 4. Dermatology

Case source Referral hotline

Case description 29 YEARS OLD Male patient on HAART SINCE 2008

CURRENTLY ON 2nd line art azt/3tc/alluvia . Current vl=

438 (2015) Known psychiatric on treatment. Currently

presents with skin condition as seen on the pictures.

Booked at lvh champ 29/11/2017

Case management • First visit: client seen and examined by doctor

29/11/2017

• Ex tb x4 last episode ptb 2016 stopped treatment in

2017

• Referred herpes zoster opthalmicus likely

superimposed bacterial infection

• Patient reports recurrent episodes of painful blisters

of face and body seen at clinic in June 2017 and

treated topically

• Face: hardened crusting rash on left side of face. In

dermatomal distribution, small fine vesicles. Peri-

orbital swelling. Decreased va of left eye

• Generalized patchy vesicular rash- body

• Plan: bloods- fbc/u+e/lft’s/cd4

• Refer to poc- blood cultures in poc, iv aciclovir,

analgesia, empiric ab

• Collect sputum gxp/tb culture, admit to poc for

treatment, discuss with ophthalmologist on call(send

pt mane to clinic)

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• consult dermatologist (poc on call)

Learning lesson Approach to skin conditions

Dermatological conditions are common at all stages of human immunodeficiency

virus (HIV) infection. Cutaneous manifestations of HIV can present as the initial sign

of HIV infection either as part of a seroconversion illness or in association with

infectious, inflammatory and neoplastic diseases, or even as a cutaneous drug

reaction. Since the advent of combination antiretroviral therapy (ART),

dermatological presentations are increasingly encountered in the setting of immune

reconstitution inflammatory syndrome (IRIS).

Although a few skin conditions occur almost exclusively in people with HIV infection,

in general, the spectrum of dermatological conditions is similar to that found in the

general population. These general dermatological problems may present as

classically seen, or be found more frequently, or be atypical in presentation.

Rash Morphology Differential Diagnosis

Follicular Bacterial, follicular eczema, eosinophilic folliculitis and

Malassezia (Pityrosporum) folliculitis

Eczematous Psoriasis, dermatitis, Reiter syndrome, drug eruptions

Papular Molluscum contagiosum, human papillomavirus, scabies

cryptococcosis, and Kaposi sarcoma, pruritic and papular

eruption of HIV

Macular / maculopapular

Secondary syphilis, parvovirus B19, disseminated candidiasis,

widespread scabies and drug reactions

Vesicular Herpes zoster (varicella-zoster virus), herpes simplex virus and

drug reactions

Petechial / pustular

Bacterial causes such as disseminated gonococcal infection,

pseudomonal or staphylococcal sepsis, infective endocarditis,

listeriosis. Also viral causes such as parvovirus B19, cutaneous

vasculitis and drug reactions

Nodular

Prurigo nodules from persistent scratching, basal and squamous

cell carcinomas, Kaposi sarcoma, mycobacteria,

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Case Title 5. Virological Failure

Case source ACC Clinical Advisor Telephonic Consult

Case description

57 year old male from Donal Fraser hospital was discussed

by ACC doctor. The patient was referred from a local clinic

with 3 consecutive unsuppressed VL. Patient started

HAART in 2007. He was on d4T, 3TC and EFV. He

developed peripheral neuropathy in 2008 and was later

changed to AZT, 3TC and EFV. In 2009, he was diagnosed

with treatment failure and changed to ddI, AZT and

Lopinavir/Ritonavir. He continued with his ARVs at the local

clinic. He was referred to hospital in October 2017 for

suspected virological failure. His latest VL was 309 000.

After strengthening Adherence; excluding TB and STIs;

ensuring that the patient is taking the correct medication

dosage; excluding chronic diarrhoea and other possible

causes of malabsorption; and excluding potential drug-drug

interactions, a Genotype Resistance Test was ordered by

ACC trained doctor. The doctor called with results and

asked for assistance. Results showed resistance to NRTI

with intermediate resistance to TDF. All NNRTIs showed

high level resistance except for Etravirine and Rilpivirine.

PIs also had resistance except for Darunavir.

We discussed the results and ensured that the blood was

collected while the patient was still on treatment. The need

for third line committee involvement was also discussed. I

then emailed the updated third line committee application

forms to the doctor for third line drugs application. The

hospital pharmacy was updated on the issue while awaiting

reply from third line committee.

Management plan

Outcome The patient is currently clinically stable and still awaiting

reply from third line committee

Lessons learnt · Criteria for patients who qualify for salvage treatment

· Access to 3rd line regimens

·

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Case Title 6. Kaposi Sarcoma

Case source CHAMP Site

Case

description

A 63 year old male, RVD reactive on HAART for 11 years presented

with left thigh swelling, bilateral lower leg oedema and generalised

lymphadenopathy. The patient reports seeing lesions on his limbs

in 2013. He also had associated reddish papules limited to the lower

legs and feet. He also had generalised lymphadenopathy. There

were no palate or mouth lesions noted. Other systems were

generally well.

The latest CD4 at the time of biopsy was 100 with a non-detectable

viral load.

Management

Plan

A biopsy was done on the left foot (papular lesions), which came

back as suggestive of Kaposi’s sarcoma with positive HHV8

markers. There was no fungal infection or granuloma formation.

The patient was referred to Polokwane Hospital Oncology

Department for treatment.

Case

outcome

The patient is currently stable with a good prognosis

Lessons

learnt

· Management of skin lesions using biopsies.

· Need to build capacity for CHAMP doctors to perform biopsies.

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Kaposi sarcoma is a spindle-cell tumor thought to be derived from endothelial cell lineage.

This condition carries a variable clinical course ranging from minimal mucocutaneous

disease to extensive organ involvement.

Signs and symptoms:

Lesions in Kaposi sarcoma may involve the skin, oral mucosa, lymph nodes, and

visceral organs. Most patients present with cutaneous disease. Visceral disease

may occasionally precede cutaneous manifestations.

Presentation:

Cutaneous lesions in Kaposi sarcoma are characterized as follows:

· Cutaneous lesions may occur at any location but typically are

concentrated on the lower extremities and the head and neck region

· Lesions may have macular, papular, nodular, or plaquelike appearances

· Nearly all lesions are palpable and nonpruritic

· Lesions may range in size from several millimeters to several centimeters

in diameter

· Lesions may assume a brown, pink, red, or violaceous color and may be

difficult to distinguish in dark-skinned individuals

· Lesions may be discrete or confluent and typically appear in a linear,

symmetrical distribution, following Langer lines

· Mucous membrane involvement is common (palate, gingiva, conjunctiva)

Diagnosis

· Punch biopsy

· Bronchoscopy

Management

· Antiretroviral therapy

· Local therapy: Radiation, Cryotherapy, Laser Therapy, surgical

· Immunomodulation: Interferon-alfa has clinical activity in Kaposi sarcoma

· Combination therapy: ABV (actinomycin D, bleomycin, vincristine)

produces higher response rates

· Cytoyoxic Agents

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Case Title 7. Hepatitis B

Case source CHAMP Site (CHAMPion Nurse) Elim Hospital

Case description 55yrs old male diagnosed with HIV since 2016. Treatment

naïve. Seemingly he had high CD4 (before Universal Test

and Treat) and was lost to care in 2017. Presenting with

Hep B surface Ag positive and Hep B core Ab positive. His

CD4 count is 385. There is no history of alcohol, no herbal

nor over the counter medication. On examination he has

jaundice, abdominal distention. He looked chronically ill

but stable. Patient was referred to CHAMP Site from PHC

through general OPD. His liver results: Albumin- 11, Total

Bilirubin 13, Conjugated Bilirubin 5, ALT 45, AST 131,ALP

220 and GGT 128. His renal function: Creatinine 87 and

eGFR more than 60.

Management plan This patient was referred to medical ward ACC trained

doctor for admission, through BZ Clinical Advisor.

Monitoring was done, glucose and clotting profiles were

normal. Patient remained alert and fully orientated. Patient

was discharged within 2 days as liver enzymes didn’t not

worsen.

Outcome ART was initiated (FDC- TDF/3TC and EFV) and he is being

followed up at the wellness clinic.

Lessons learnt · Management of HIV and Hep B co-infection –

importance of using TDF and 3TC to treat both

conditions.

Understanding the natural history of HBV and knowing how to interpret hepatitis

B serologic studies are keys to evaluating the current stage of HBV infection and

determining who may benefit from HBV treatment.

There are 3 main phases of chronic HBV disease as follows:

1. Immune tolerant phase: This phase is characterized by a high level of HBV

replication with little or no evidence of active hepatic inflammation. Hepatic

transaminases are normal and liver biopsy, if performed, would show little or

no inflammation. Most children infected at birth or during early childhood will

be immune tolerant and remain in the immune tolerant phase for years or

even decades; however, most eventually will progress to immune active

disease. HBV DNA is detectable, as are HBeAg and hepatitis B surface

antigen (HBsAg). Because of the high level of HBV viremia, this is a highly

infectious phase.

2. Immune active phase: This phase is characterized by elevated liver

enzymes and liver inflammation on biopsy. Individuals infected in

adolescence or adulthood, as is frequently seen in HIV/HBV coinfection in

the United States, often begin the disease course in the immune active

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phase, and are never immune tolerant. This phase also is characterized by

detectable HBV DNA, HBeAg and HBsAg, and risk of transmission to others.

3. Inactive carrier phase: During this phase, HBeAg is lost and HBV DNA

declines, often to undetectable levels. Hepatitis B e antibody (HBeAb)

seroconversion can occur, followed by hepatitis B surface antibody (HBsAb)

seroconversion, indicating immune control of HBV infection. A small

proportion of people will continue to have detectable low-level HBV DNA,

which may be intermittent and is referred to as "occult" HBV infection

Diagnosis of HBV in HIV Infection

Given the elevated rates of HBV among individuals who are infected with HIV

and the shared routes of transmission between the two viruses, all HIV-infected

individuals should be screened for HBV coinfection with HBsAg testing. Patients

who do not have evidence of HBsAg should have HBcAb and HBsAb evaluated

to assess for prior HBV infection as well as HBsAb, which provides evidence of

immunologic control of prior infection or vaccination

Management of HBV in HIV-Co infected Individuals

The combination of TDF with 3TC or FTC is recommended as a highly effective

first-line treatment for HBV. Individuals who cannot take TDF because of renal

insufficiency or other intolerance may consider entecavir treatment (renally

dosed if necessary) for HBV in lieu of TDF. Treatment with 3TC or FTC as the

only HBV-active agent in ART (ie, HBV monotherapy) is not recommended owing

to a high risk of developing HBV drug resistance over time.

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Case Title 8. Spontaneous Pneumothorax with PTB

Case source TB Ward Round Nkhensani Hospital

Case description

A 19 year old boy, RVD negative, with PTB was referred

from the local GP. He presented with a 5/7 history of cough,

fever, chest pain and dyspnoea. No history of trauma or

injury was provided. There was no history of chronic lung

disease or known previous lung infections. The initial

assessment and x-rays findings were L-sided pneumonia

and L mediastinal shift.

Management plan Sputum Gene Xpert done was positive, Rifampicin

sensitive. Sputum AFB was negative. On review at the

hospital, the patient was found to have a spontaneous L-

sided pneumothorax. A chest drain was inserted, and the

patient was admitted. He developed an empyema during his

stay in the ward.

We discussed this case with our CHAT (Radiologist) and

Cardiothoracic Surgery Polokwane. Based on the x-rays

sent to our CHAT, a diagnosis of bronchi -pleural fistula was

made. The patient was booked for review at Polokwane

cardiothoracic department.

Outcome Cardiothoracic Surgery Department is still managing the

patient. CT-scan (chest) was done and a fistula was

confirmed. The patient is awaiting an operation (possibly a

Pleurodesis).

Lessons learnt · Extra-pulmonary TB in HIV negative patients

· Surgical management of an infectious disease

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Case Title 9. Poly Drug Resistance TB

Case source District Review Meeting (Mopani District)

Xdddd Case

description

The district office requested Beyond Zero to follow up with

a case that has gained the interest of the National

Department of Health in January 2018. The patient is a 28

year old male, RVD reactive currently on MDR TB

treatment. The patient is known to The Provincial MDR TB

Unit with INH and Ethambutol Resistant MTB since 2015.

The patient was recently referred to Nkhensani Hospital

from MDR TB Unit, through Kgapane Hospital. The current

concern is the patient’s TB Regimen being queried by

Provincial TB Team.

The patient is currently on:

Rifampicin 600mg daily

PZA 1500mg daily

Levofloxacin 1000mg daily

Terivaldin 750mg daily

Paser Granules 8g daily

Clofazimine 100mg daily

Pyridoxine 150mg daily

Maxolon 10mg daily

Background History

The patient is currently on room air,

The patient had previous TB in 2013. The extent of the TB

is unclear in the records reviewed. It is also unclear if it

was drug-sensitive or resistant TB. The treatment duration

was also not specified in the records. The patient was

unfortunately not interviewed at the time of records review.

The patient’s medical history of other chronic illnesses is

also scanty. It seems the HIV was only diagnosed 3

months ago at Nkhensani Hospital. The patient has since

been on FDC (Tenofovir/Emtricitabine/Efavirenz). The

latest CD4 count was not available in the patient file. The

patient is still awaiting 6 month VL collection.

There is no history of surgery/operations or allergies listed

in the patient file.

His work history is unremarkable. There is no known

history of exposure to mine work or asbestos. His current

employment history was not stated in the file.

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Investigations

His sputum results (from 2015) - Gene Xpert positive,

Rifampicin sensitive. INH resistance with InHA and KatG

mutations. Ethambutol resistance also found. There is no

resistance to second line drugs. A sputum repeat was

done in October 2017. It still shows Rifampicin sensitive

MTB with INH resistance and sensitive to 2nd line drugs.

No mention of Ethambutol resistance in new results.

X-rays done. There is fibrotic changes in the upper zone of

the left lung with a complete whiteout of the mid and lower

zones. There are also cavities in upper left zone. The

mediastinum is seemingly shifted to the right. The right

lung has diffuse infiltrates with mid zone cavitations.

ECG and Hearing Tests done

Latest blood results

U&E: Na- 131, K-5.4 H, Urea and Cr within normal limits.

LFT: Albumin- 29, TSB- 2, ALT-5, AST- 15, ALP- 135 H,

GGT 39

FBC: Hb- 13 L, MCV- 81 L, MCH 26.6 L, Platelets- 482

CMP: 2.02 L, 1.05, 1.13

TSH- 5.76 H; T3- 5.8

Case outcome This is an unusual and uncommon resistance pattern

noted in the lab blood results.

The regimen in question was written as is from MDR Unit

Nkhensani Hospital continued what was structured from

the Provincial MDR Unit

The ACC trained and CHAMP doctor completed request

forms to National TB doctors for assistance with regimen

structuring.

We forwarded the case to our CHAT TB Specialist Dr

Mphothulo.

Dr Mphothulo’s reply:

This is an interesting and rare case.

We replace INH with Moxafloxacin (in this case he is on

Levofloxacin). We replace Ethambutol with Ethionamide, in

this case he is resistant to Ethambutol so also Ethionamide.

However Ethambutol is not really an important drug, it is

there to prevent Rifampicin resistance.

So a suggested regimen (12 months)

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1. Rifampicin

2. PZA

3. Moxafloxacin (Levoflaxacin is also fine)

Strange things on the current regimen:

1. Why did they use Levoflaxacin instead of

Moxafloxacin?

2. Why PASA and Clofazamine?

So they treated a patient with poly drug resistance as pre-

XDR and that is probably why the province is questioning

this regimen. It disadvantages the patient by skipping

second line drugs to XDR drugs

Prognosis The patient’s regimen has been adjusted as per CHAT

recommendation. The patient is currently stable and

clinically well. He is attending regular follow ups at CHAMP

hospital.

Lessons learnt · The importance of repeating an HIV test in patients on

TB treatment

· The value of a TB expert when faced with rare TB

resistance patterns

· The importance of thorough documentation with inter-

hospital transfers

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Case Title 10. Acute Confusional State

Case source CHAMP Site

Case description

A 32 year old female was seen at CHAMP site (within the

same hospital) for treatment initiation on 04/01/2018. The

patient tested HIV positive in the ward and had been

admitted for a week prior to CHAMP site referral. On

discharge, the patient was sent to CHAMP site with the

following results:

CD4= 707, VL= 247, Hb=14.1, Creatinine= 61, TSB= 11,

ALT/AST within normal limits.

The CHAMP site did not have the patient’s admission notes

or diagnosis.

The patient was initiated on TDF/FTC/EFV (FDC)

Case outcome Beyond Zero Clinical Advisor audited the file as per routine

support visit. The following information raised red flags:

ACC trained doctors were not available on day of patient

review

CHAMPion nurse was on annual leave at time of patient

review

Patient history taking was not done as patient was seen to

have been “looking rigid” and seems to be “deep in thought”

A chronic script signed in the ward post discharged had

hypertension medication (Amlodipine, HCTZ and Aspirin)

and Disipal

The patient’s admission medical records were traced and

showed that patient was initially admitted with confusion.

During the patient’s stay in the ward, psychotic features

were detected and the patient was put on antipsychotic

medication.

The gap still remaining why how the patient was discharged

on Disipal only and why FDC was initiated.

A support visit was done in the medical ward where it was

made clear that the patient had received IMI antipsychotic

medication and had later developed extra-pyramidal side

effects. Oral antipsychotics were stopped and the patient

was for review in a week at General OPD.

The CHAMPion nurse was now back at the site and was

updated on the patient’s details. The patient is to be traced

back to the facility and FDC to be stopped. The Efavirenz in

a recently discharged psychotic patient should be

substituted.

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Prognosis The patient missed General OPD review but was followed

up through CHAMP site. A mental health review will be done

again on 01 February 2018

Lessons learnt (1 or

more)

· The importance of Advanced Clinical Care training

· Documentation is crucial for discharged patients for

summarising admission diagnosis, final diagnosis and

what transpired in the ward

· Patient co-morbid conditions should be documented in

ART file as well

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Case Title 11. Obstructive Jaundice

Case source Ward Round CHAMP Site (Kgapane Hospital)

Case description

A 46 year old female, RVD reactive on FDC, consulted in

July 2017 at OPD with left upper quadrant pain post alcohol

binge spree. She was seen at her local clinic and her

treatment was non-specific. She received anti-emetics and

antacids. She was well until August 2017 when she

presented with right upper quadrant pain, jaundice, nausea

and vomiting. She was managed as an outpatient case as

her Total Bilirubin was below 50. Her AST and ALT were

minimally elevated and her ARVs were continued at the

local clinic. She was referred to hospital for further

management as her vomiting persisted and she felt that her

pain was not improving.

Case outcome Document results and further management

She was admitted in October 2017 for a week and her ARVs

were adjusted. Efavirenz was changed to

Lopinavir/Ritonavir. There was no clear indication of her

CD4 count or viral load at the time of treatment adjustment.

She was worked up further, Malaria, Hepatitis A, B, C and

TB were excluded as possible causes of jaundice. She was

discharged after a week in hospital.

She came back in November 2017 and was still not getting

well. Her full Liver Enzyme picture showed: TSB= 192,

Conjugated Bili= 177, ALT= 161, AST =161, ALP= 1266,

GGT= 2081. Her Haemoglobin is 8.2 with normal WCC and

Platelets.

At this point, it was clear that the patient most likely had an

obstructive jaundice based on liver enzyme profile. Her

Alpha feto-protein (AFP) was normal and CEA was also

normal.

Prognosis The patient was referred to the Surgical Department for

further workup. She was booked for U/S with Polokwane

hospital. She is currently undergoing care in the Surgical

Unit in Polokwane.

Lessons learnt (1 or

more)

· The significance of a full liver enzyme profile in patients

not responding well to medical treatment

· Challenges facing hospitals that need to refer to Tertiary

Hospital for non-invasive radiology

· Patient evaluation should start with history taking and

general examination. Surgical conditions can be

diagnosed clinically with good clinical suspicion

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Case Title 12. Extra-Pulmonary TB

Case source Ward Round (Nkhensani Hospital)

Case description A 43 year old male, RVD negative, was being treated for

extrapulmonary TB in November 2017. He was diagnosed

on x-ray (Miliary pattern) with no ascitic fluid, CSF or bone

marrow specimens. The patient developed constipation

which persisted for a week despite stool softeners being

given. Abdominal x-rays were done (erect and supine)

which showed air fluid levels and distended small bowel

loops.

Management plan The patient was put on bowel rest (nil per os) with naso-

gastric tube drainage. A fleet enema was also ordered. IVI

fluids with dextrose 5- 10% were given during the bowel rest

period.

Outcome The patient improved and started passing stools well. Soft

feeds were introduced then solids. The patient was later

discharged. Intra-abdominal adenopathy secondary to TB

was clinically suspected as the possible cause.

Prognosis Patient is doing well.

Lessons learnt · Extrapulmonary TB can involve multiple organ systems

· Basic surgical principles such as nasogastric tube

drainage can be life-saving

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Case Title 13. Renal Dialysis

Case source CHAT WhatsApp Group

Case description A 50 year old male was presented by ACC doctor in

Maphutha Malatjie Hospital. Patient was intitiated on

TDF/3TC/EFV. The patient developed severe renal failure

(Creatinine > 1000) and TDF was stopped. The patient

undergoes dialysis at a private facility 3x a week.

Case management The ACC trained doctor wanted to find out how dialysis

affects ARV administration and dosages. Our CHAT

member and researcher replied in the group quoting an

article published in American Society of Nephrology by

Berns et al from the University of Pennsylvania School of

Medicine. The article suggested giving medication after

dialysis (the evening in the case of our patient).

Outcome The patient is currently stable on dialysis. The shared

information continues to assist other doctors with

management of patients on dialysis.

Lessons learnt · The importance of having experts readily available in

WhatsApp groups for doctors to consult at any time

· The challenges of getting renal dialysis in the public

sector for state patients

· How to manage patients on ART receiving dialysis

Case Title 14. Drug-Drug Interaction

Case source CHAT WhatsApp Group

Case description A 30 year old female was reported in the group. She is an

epileptic patient on Carbamazepine and Sodium Valproate

for 2 years. She was controlled on the 2 drugs. The ACC

doctor is worried because the patient is currently RVD

reactive and needs to start HAART. The doctor was worried

about carbamazepine interaction with both NNRTIs and

PIs. The doctor is also worried about the potential for

treatment failure and poor seizure control.

The CHAT advised the patient to adjust sodium valproate

dosage based on how the patient responds to treatment.

With poor control, additional medication can be used i.e.

Lamotrigine and Gabapentin.

Case outcome The patient was eventually put on Lamotrigine (in addition

to Sodium Valproate) and is now well controlled. The

Lessons learnt · The value of ACC training in anticipating and avoiding

drug-drug interaction

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· The challenges of getting additional epilepsy treatment

in district hospitals

· Management of patients with HIV and epilepsy.

· Management of drug-drug interactions (ARVs and

antiepileptics)

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Case Title 15. Stevens Johnson Syndrome

Case source CHAT WhatsApp Group

Case description A 44 year old, female, known with Schizophrenia, at St Ritas

Hospital was seen and admitted. She was initiated on

TDF/FTC/NVP 3 weeks prior to her admission. NVP was

gradually increased over 2 weeks up to a dose of 200mg

bd. Unfortunately, a CD4 of 566 was later discovered when

the patient was admitted.

The patient developed Stevens Johnson Syndrome and

was admitted. ART was stopped during admission.

The ACC trained doctor wanted to know which treatment to

continue the patient on. The patient was put on a PI based

regimen.

Case outcome The patient improved and was discharged from the hospital

Lessons learnt · NVP should be initiated as per National DOH guidelines

to prevent complications

· Avoiding potential drug interactions and side effects can

lead to choosing drugs not commonly used anymore

· Management of HIV in mental health users

· Initiating NVP at high CD4 counts

· Management of Steven Johnson’s Syndrome

Stevens-Johnson syndrome is a type IV (subtype C) hypersensitivity reaction that typically

involves the skin and the mucous membranes

· Stevens-Johnson syndrome: A minor form of toxic epidermal necrolysis, with less

than 10% body surface area (BSA) detachment

· Overlapping Stevens-Johnson syndrome/toxic epidermal necrolysis: Detachment of

10-30% of the BSA

· Toxic epidermal necrolysis: Detachment of more than 30% of the BSA

Signs and symptoms

Typical prodromal symptoms of Stevens-Johnson syndrome are as follows:

· Cough productive of a thick, purulent sputum

· Headache

· Malaise

· Arthralgia

Diagnosis

Minimal dermal inflammatory cell infiltrate and full-thickness necrosis of the epidermis are

typical histopathologic findings in patients with Stevens-Johnson syndrome

Management

Patients should be treated with special attention to airway and hemodynamic stability, fluid

status, wound/burn care, and pain control. Therapy for Stevens-Johnson syndrome

proceeds as follows:

· Withdrawal of any agent suspected of causing the condition is critically important

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· Oral lesions are managed with mouthwashes; topical anesthetics are useful in

reducing pain and allowing the patient to take in fluids

· Areas of denuded skin must be covered with compresses of saline or Burow solution

(an aqueous solution of aluminium triacetate)

· Tetanus prophylaxis must be addressed

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Case Title 16. Adverse reaction to treatment

Case source Referral Triage line from Bye boom clinic

Case description 34 year old woman started treatment in 2012 ( TDF,

3TC,EFV )

She was switched to second line in 2014 ( KALETRA,3TC

and AZT )

She was again put on FDC in 2017 ( By mistake they

reported )

She was now presenting with severe loss of weight, sores

on the vulva but not septic.

She was then referred to Tshilidzini hospital, admitted and

discharged same day and was discovered by a home based

carer

An arrangement was made through triage and the clinic

professional nurse to transfer patient back to the hospital

The Project officer of Vhembe was also informed to track

down the patient in hospital

Management plan Patient got admitted in hospital

She was put back to second line regimen and discharged

after two weeks

Prognosis She is much better and was allocated a carer to visit her on

regular bases

Lessons learnt · Communication between Triage officer, hospital and

clinic staff made it possible for the patient to get help on

time

· Importance of documenting prior drug history

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Case Title 17. PCR Positivity

Case source ACC Clinical Advisor Telephonic Consult

Case description A 9 month old boy HIV exposed, with positive birth PCR,

currently on ABC/3TC/Kaletra since 2016 is being managed

in Hospital. The ACC doctor’s main concern was lack of

confirmatory test done before ART initiation. Current VL is

LDL and CD4 count (4459) - percentage not included. The

doctor repeated a PCR querying the child’s positivity status.

The repeat PCR is negative. The child is clinically well and

without any current problems.

Case outcome The case was sent to CHAT (Virology). They were

unfortunately unable to retrieve the patient details from

NHLS. The advice was to continue ART and close

monitoring. The patient was likely positive given the first

PCR test. The repeat PCR with LDL VL is most likely

influenced by HAART.

Prognosis The patient is still on treatment and virologically

suppressed.

Lessons learnt (1 or

more)

· The importance of PCR confirmatory test before starting

HAART

· The complexities of collecting PCR when the patient is

already on treatment

· Management of discordant PCR results