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Pus aspirated – ZN pos, GeneXpert Rif Resistant
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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
M41L D67N V75IM M184V L210W T215Y A98G V106I Y188L
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)