Case 12

42 year-old female

From South Asia

In UK 8 years

Living in London

Case 12: Feb 2008

Seen in a London ED and admitted to hospital with:

• Night sweats• Weight loss (4kg)• Intermittent shoulder pain• Lesions on legs • Subsequent rash on face (burning), legs,

forearms and trunk (mildly itchy)

Case 12: inpatient • 3-night hospital admission - treated with

‘antibiotics’. Discharged.• Diagnosed with erythema nodosum and chicken

pox on clinical grounds• No investigations for TB or HIV

But referred to Respiratory Medicine - ?

Case 12: March 2008

Seen in Respiratory OPD• PUO queried• TB Elispot positive• Chest X-ray clear• ESR and CRP elevated• Abnormal liver function tests (ALP 121,ALT 198)• Hepatitis B serology ‘previous infection’• LATENT TB DIAGNOSEDReferred to Dermatology for rashes on face

and body

Case 12: April 2008

Seen in Dermatology OPD• Face - fixed erythema + papules/pustules –

rosacea clinically• Legs - indurated nodular lesions – erythema

nodosum clinically • Non-specific eczematous eruption on trunk,

forearms • Nodular indurated lesions on hands

Case 12: April 2008

Differential Diagnosis:• Cutaneous tuberculid• Lupus erythematosus • Sarcoidosis• Rosacea (face)• HIV

Case 12: April 2008Investigations:• Skin biopsies

– Non specific perivascular inflammation– Fungal stains negative– IMF negative– Fungal/AFB/bacterial cultures- negative

• Elevated IgA & IgG• Autoimmune profile negative • HIV antibody positive• CD4 198; VL 22,738

Case 12: summary2000 Registered with GP

Feb 2008 General medical admission

March 2008 Seen in Respiratory OPD – PUO queried, previous Hep B identified, latent TB

diagnosed

April 2008 Seen in Dermatology OPD; cryptic presentationHIV diagnosed: CD4 198: VL 22,738

Q: At which of her healthcare interactions could HIV testing have been performed?

1. When she first registered with her GP?

2. When she presented to the ED with weight loss and was admitted?

3. When she presented to Respirology OPD with suspected PUO, previous Hep B was identified and latent TB was diagnosed?

4. Should she have been referred to GUM to see a trained counsellor before HIV testing?

Who can test?

Who can test?

Who to test?

Who to test?

13

Rates of HIV-infected persons accessingHIV care by area of residence, 2007

Source: Health Protection Agency, www.hpa.org.uk

Who to test?

Who to test?

2000 Registered with GP

Feb 2008 General medical admission, weight loss

March 2008 Seen in Respiratory OPD - PUO queried, previous Hep B identified, latent TB diagnosed

April 2008 Seen in Dermatology OPD; cryptic presentationHIV diagnosed: CD4 198; VL 22,738

3 missed opportunities! If current guidelines used, HIV could have been diagnosed up to 8 years earlier

Learning Points• This patient came from a country of low HIV prevalence

and was probably not believed to be at risk of HIV infection

• Because of this the otherwise excellent medical teams looking after her presumably did not think of HIV even though the diagnosis seems obvious with hindsight

• However, the suspected PUO and Hepatitis B and TB diagnoses were a red flag for possible HIV infection

• A perceived lack of risk should not deter you from offering a test when clinically indicated

• Antiretroviral therapy (ART) has transformed treatment of HIV infection

• The benefits of early diagnosis of HIV are well recognised - not offering HIV testing represents a missed opportunity

• UK guidelines recommend screening for HIV in adult populations where undiagnosed prevalence is >1/1000 as it has been shown to be cost-effective

• HIV screening should be a routine test on presentation of PUO or weight loss of otherwise unknown cause

• HIV screening should be routine in services for patients diagnosed with Hepatitis B and TB

Key messages

19

Also containsUK National Guidelines for HIV

Testing 2008

from BASHH/BHIVA/BIS

Available from:

enquiries@medfash.bma.org.uk or 020 7383 6345