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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.
2 | P a g e
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
4 | P a g e
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.
6 | P a g e
· 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)
8 | P a g e
• 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,
9 | P a g e
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.
11 | P a g e
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
12 | P a g e
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
13 | P a g e
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.
14 | P a g e
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.
16 | P a g e
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)
17 | P a g e
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
18 | P a g e
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.
19 | P a g e
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
20 | P a g e
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
21 | P a g e
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
22 | P a g e
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