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Formal patient case Presentation:

Formal patient case Presentation Stage IV RVI + Neurotoxoplasmosis + oral thrush 5/3/2012

Case summary :

Case summary Patient’s Name: T.F. Card Number: 200782 Age: 25 Sex: F Address: Serbo Occupation: Elem. school teacher 5/3/2012

C/C::

C/C: 5/3/2012 Vomiting of 2mo Dry cough High grade fever Severe headache

Subjective Data:

Subjective Data 5/3/2012

HPI:

HPI T.F. was relatively okay before 2 months T.F. was then suffering from severe vomiting, for which she had been frequently treated as gastritis T.F. has No Hx of diarrhea or constipation No hx of TB 5/3/2012

PMH::

PMH: She had no known chronic disease treated but, Had hx of Malaria and gastritis 5/3/2012

FH:

FH Her husband is alive and okay T.F has a five year boy Both (Her husband & her child)do not know their sero-status but willing to do it in near future 5/3/2012

Allergies::

Allergies: NKDA 5/3/2012

Immunizations::

Immunizations: Childhood vaccination not known She was vaccinated during her recent pregnancy (TT?) and participated in mass vaccination 3 years before (she mentioned ‘meningitis prevention vaccination’) 5/3/2012

Home medications::

Home medications: She had frequently been using home made medication using some herbals (from local traditional healers) 5/3/2012

Medication history :

Medication history She was buying and using omeperazole capsules (pelleted capsules) PRN for the relief of her gastritis, after once she has identified it being prescribed from the local health center 5/3/2012

Objective Data:

Objective Data 5/3/2012

Physical examination (hospital Visit) :

Physical examination (hospital Visit) G/A: Chronically sick looking V/S PR:102 RR:30 BP:100/70 Temp.:36.7 HEENT: Pink conjunctiva Wet tongue and buccal m. 5/3/2012

P/E…:

P/E… Pinkish oral thrush on her tounge and b/n teeth Chest: C & R CVS: S1 & s2 well heard No ‘m’ or ‘g’ Abd: flast and moves with resp. 5/3/2012

P/E…:

P/E… GUS: INTG.: NAD MSS: right side paraparesis NS: slight mental confusion other wise COPTT ASS.: stage IV RVI with sec. OIs 5/3/2012

Vital signs :

Vital signs Date (D/M/Y) VITAL SIGNS 02/08/04 E.C PR/min RR/min BP(mmHg) T (0c) Wt (Kg) 03/08/04 E.C 86 23 100/70 36.7 40 04/08/04 E.C 88 20 100/70 36.2 05/08/04 E.C 84 18 100/70 35.7 10/08/04 E.C 80 20 100/80 35.9 12/08/04 E.C 104 22 100/80 36.1 5/3/2012

PowerPoint Presentation:

5/3/2012 Investigation dates and Reference value Chemistry 02/08/04 Conventional Units Electrolytes: RFTs: Na 135–145 mEq/L K 3.3-4.8mEq/L Ca 9-10.6mg/dl Mg 1.8-2.5mg/dl BUN 6.9mg/dl 8–25 mg/dL BUN/Cr 10:1 to 20:1 Scr. 0.8mg/dl 0.5-1.3mg/dl Laboratory Values

PowerPoint Presentation:

5/3/2012 Investigation dates and Reference value CBC (peripheral blood) 02/08/04 Conventional Units WBC 3.7X10 3 3.54–9.06x10 3 /mm 3 Hgb 11.4mg/dl 12.1–15.1 g/dL (female) HCT 35% 36.1–44.3% (female) Neut 61% 1420–6340/mm (40–70%) lymph 27% 1.2–3.3 × 103/μ L (25–35%) Mono (140–720/mm 3 )2–6% Bands (0–450/mm 3 ) 0–5% Eos (0–540/mm 3 )0–3% Baso (0–180/mm 3 )1–3% CD4 lymphocyte count 21 31–61% of total lymphocytes ESR 0–20 mm/h

PowerPoint Presentation:

5/3/2012 Investigation dates and Reference value CBC (peripheral blood) 02/08/04 Conventional Units MCV 76.6 80.0–97.6 μ m3 MCH 25pg 26–34 Pg (for 18-49 age person) MCHC 32% 31–37 % (for 18-49 age person) HBsAg CD4 Negative 21cells/ μ l Negative ≥500/μ L or ≥29% Or 31–61% of total lymphocytes H.Pylori Ab test negative negative

PowerPoint Presentation:

5/3/2012 Investigation dates and Reference value 02/08/04 Conventional Units LFTs Other tests Total protein Alk phos. 384 IU/L 6.0–8.0 g/dL 38–126 IU/L (age >20) Albumin 3.5–5.0 g/dL AST 40 IU/L 11–47 IU/L ALT 25 IU/L 7–53 IU/L GGT 0–30 IU/L Total Bili. 0.6mg/dL 0.3–1.1 mg/dL Dir. Bili 0.2mg/dL 0–0.3 mg/dL Indir.bil 0.1–1.0 mg/dL Cr.Cl 85–135 mL/minute/1.73 m2

PowerPoint Presentation:

5/3/2012 Investigation dates and Reference value Conventional Units Fating lipids Other tests Total cholesterol Less than 200 mg/dL LDL Less than 130 mg/dL HDL Greater than 35 mg/dL TGs Less than 160 mg/dL Platelets 140–440 × 103/μ L PT/INR 4.5 aPTT 25–40 s PT 10–12 seconds INR 2.0–3.0 (2.5–3.5 for some indications)

PowerPoint Presentation:

5/3/2012 Investigation dates and Reference value 02/08/04 Conventional Units U/A Microscopy pH 5 4.8–8.0 Sp.gr 1.020 1.005–1.030 Blood + negative Ketones negative negative Protein negative negative nitrites negative Glucose WBC RBC negative 2-4 5-6 negative 3–4 per low-power field 1–2 per low-power field Bacteria Epithelial cells many

Assessment:

Assessment 5/3/2012

Working diagnosis:

Working diagnosis (01/08/04) Severe CAP + R/O PTB + Stage IV RVI Revised: (02/08/04) Stage IV RVI +Right sided hemiparesis secondary to CNS Toxoplasmosis + oral candidiasis + dyspepsia 5/3/2012

Medications:

Medications Sr.no Date Medications 1 03/08/04 Fansidar 2 tab po bid Atenolol bid??? TMP-SMT 2 DS tabs po /d 2 04/08/04 Fansidar 2 tabs po bid for today and then TMP-SMT 2SS tabs po bid for 3 wks Antacid susp. 2tsp po prn Miconazole oral jel 2tsp po bid 3 08/08/04 TMP-SMT 2 SS tabs po bid (continued) Miconazole oral jel 2tsp po bid(continued) 4 11/08/04 The same plus Plasil 10mg po prn 5/3/2012

Clinical Questions:

Clinical Questions When exactly to initiate HAART for T.F? How should CNS Toxoplasmosis and oral candidiasis be managed ? Does Fansidar or CTM be as effective as the pyrimethamine- sulphadiazine/ clindamycin combinations? Does the hemiparasis in this patient need additional therapy? 5/3/2012

Articles Review (1):

Articles Review (1) Manuel Battegay, Antiretroviral therapy of late presenters with advanced HIV disease Journal of Antimicrobial Chemotherapy: (2008) 62,41–44 Importantly, data from recent studies clearly indicate that early combination ART is advantageous when opportunistic infections are present (except in TB and Crypto.) It has been shown that delaying combination ART is associated with increased mortality . 5/3/2012

Articles Review (2):

Articles Review (2) RCT of pyrimethamine-sulphadizine for therapy of toxoplasmic encephalitis in patients with AIDS American Society for Microbiology Compares: TMP-SMX Vs Pyrimethamine- Sulphadiazine Patients randomly assigned to receive either TMP (10mg/kg/d) and SMX (50mg/kg/d) or P (50mg/kg) and S (60mg/kg) 5/3/2012

PowerPoint Presentation:

5/3/2012 For 4wks (acute therapy) Then for 3mo (maintenance therapy) 77 patients were enrolled 40 patients: TMP-SMX 37 patients: P-S Result=> no statistical difference in acute therapy More radiological resolution result was observed in the TMP-SMX group (maintenance therapy) ADRs were more common in the P-S group TMP-SMX is equally efficacious as P-S in the Rx of neurotoxoplasmosis

Articles Review (3):

Articles Review (3) Treatment of oral thrush in HIV/AIDS patients with lemon juice and lemone grass Science direct amd on PUBMED Result: The use of lemon juice and lemon grass for the treatment of oral candidiasis in an HIV population was validated by RCT 5/3/2012

Articles Review (4):

Articles Review (4) Single dose fluconazole vs std 2wk therapy for oropharyngeal candidiasis in HIV infected patients: A Randomized double blind study Journal of clinical infectious diseases (Oxford Journals) 220 patients assigned with 1: 1 ratio Single dose of fluconazole 750mg po was equivalent to a 14 day 200mg/d fluconazole in achieving clinical and mycological cure. ADR also unknown and not significant 5/3/2012

Articles Review (4):

Articles Review (4) Role of Posaconazole in the management of oropharyngeal and esophageal candidiasis PUBMED:V3(4), aug, 2007 Compares the current std care for oral thrush and oropharyngeal candidiasis ( fluconazole and itraconazole Vs Posaconazole) Posaconazole appears to be more effective than the STD in sustaining successful clinical outcome and maintains symptoms free period 5/3/2012

Drug therapy problems Assessed::

Drug therapy problems Assessed: 1.Unnecessary drug therapy Atenolol was provided to the patient unnecessarily 2.Needs additional drug therapy HAART should be initiated soon Corticosteroids for hemiparesis and CNS toxo manifestaion Lemon juice for oral thrush (adjuvant) 5/3/2012

DTPs…:

DTPs… 3.Ineffective drug: not identified but, incomplete Fansidar regimen for toxo 4. Under dose The dose of CTM for the acute phase was low 5/3/2012

Overview of CNS Toxoplasmosis:

Overview of CNS Toxoplasmosis Toxoplasmosis is a zoonotic disease caused by the obligate intracellular protozoa T. gondii. Infection in humans usually occurs via the oral or transplacental route. 5/3/2012

PowerPoint Presentation:

5/3/2012 Consumption of raw or undercooked meat containing viable cysts, water contaminated with oocysts from cat feces, and unwashed vegetables are the primary routes of oral transmission.

PowerPoint Presentation:

5/3/2012 patients with HIV are at risk for developing acute toxoplasmosis due to reactivation of the organism if their CD4+ T-cell count decreases below 100 cells/µL or if this level decreases below 200 cells/µL in the presence of concomitant opportunisti c infection or malignancy.

PowerPoint Presentation:

5/3/2012 Empiric therapy for cerebral toxoplasmosis should be considered in all HIV-infected patients with ring enhancing lesions found on MRI and/or CT . In most cases, negative serology for antitoxoplasma IgG antibodies should prompt the physician to consider diagnoses other than toxoplasmosis in HIV-infected patients. However, negative serology does not conclusively rule out acute toxoplasmosis.

TOXOPLASMOSIS AND IMMUNE RECONSTITUTION SYNDROME (IRIS):

TOXOPLASMOSIS AND IMMUNE RECONSTITUTION SYNDROME (IRIS) IRIS may complicate CNS infections, as has been well described for mycobacteria and cryptococcal infections; however, fewer cases of IRIS related to CNS toxoplasmosis have been reported 5/3/2012

PowerPoint Presentation:

5/3/2012 IRIS in association with toxoplasmosis can lead to a paradoxical worsening of symptoms with worsening edema surrounding brain lesions as CD4 cell counts rapidly improve Management includes continuing treatment for TE and HIV and increasing the dose of steroids as needed to control symptoms.

PowerPoint Presentation:

5/3/2012 DIAGNOSIS General principles: A definitive diagnosis of TE requires a compatible clinical syndrome; Serology: seropositive for anti-toxoplasma IgG antibodies, Anti-toxoplasma IgM antibodies are usually absent Imaging: ring-enhancing brain lesions Brain biopsy: Definitive diagnosis

PowerPoint Presentation:

5/3/2012 TREATMENT The initial drug regimen of choice is the combination of pyrimethamine (200 mg loading dose PO followed by 75 mg/day) plus sulfadiazine (6 to 8 g/day PO in four divided doses) or pyrimethamine plus clindamycin Folinic acid ( leucovorin ) must always accompany pyrimethamine therapy to prevent hematologic toxicity

PowerPoint Presentation:

5/3/2012

PowerPoint Presentation:

5/3/2012 TMP-SMX 4tabs po bd / 4wks (acute therapy), then 2tabs po bd 12 wks ( maintainance therapy), 2tabs po /d life long (prophylaxis) The 1st line regimen in the Ethiopian is: Sulfadoxine / pyrimethamine ( Fansidar ): 500 mg/ 25 mg po BID for 2 days, followed by once daily both for 4 wks PLUS Folinic acid (10 mg daily)

PowerPoint Presentation:

5/3/2012

Comparing pyrimethamine + sulfadiazine Vs Fansidar doses for neurotoxoplasmosis:

Comparing pyrimethamine + sulfadiazine Vs Fansidar doses for neurotoxoplasmosis Pyrimethamine + sulfadiazine Pyrimethamine +sulfadoxine Pyrimethamine loading/first day 200mg + 75mg/d 50mg pyrimethamine on first day(2fansidar tabs ) Intensive phase (up to 4wks) 75 mg /d 25mg/d +50 mg of pyrimethamine of the 2 nd day Total dose of pyrimethamine during intensive phase (4wks) 2525mg/4wks 900mg/4wks 5/3/2012

Hemiparesis:

Hemiparesis paraplegia is more severe form of paraparesis. Cause: anything that can harm CNS (stroke, head injury, D.M , brain tumor, infections , vasculitis, hereditary problems (leukodystrophies)etc. 5/3/2012

PowerPoint Presentation:

5/3/2012 Dx : CBC, blood chemistry, cranial CT or MRI, EEG Rx: Main stay of therapy for paraparesis is physiotherapy and use corticosteroids in infectious origin

Plan:

Plan 5/3/2012

Plan to solve drug therapy problems:

Plan to solve drug therapy problems HAART should be initiated soon TDF+3TC+NVP (planned) TDF=> normal RFTs NVP=> normal LFTs plus possibility of pregnancy Physiotherapy for hemiparesis 5/3/2012

PowerPoint Presentation:

5/3/2012 MRI and CT scan as well as serological test should be included for further investigation occurrence of seizure should be closely monitored. Corticosteroids should be added as adjuvant therapy to prevent both the occurrence of seizure and IRIS Patient should be advised to use lemon juice oral hygiene

Decision Made ::

Decision Made : Health education was provided Toxo preventions The benefit of ART Benefit of checking sero-status of her husband and child Use of lemon juice for prevention of oral thrush (mouth wash) TDF+3TC+NVP was selected discussing with the residents 5/3/2012

Discharge medications :

Discharge medications TMP-SMT 2 SS tabs po bid (continued) Miconazole oral jel 2tsp po bid(continued) Anatacid suspenson 2tsp po PRN Plasil 10mg po PRN # 10 tabs 5/3/2012

Clinical pharmacists’ recommendation on discharge medications::

Clinical pharmacists’ recommendation on discharge medications: TMP-SMT 2 and 1/2 SS tabs po bid for the next 3 wks, then for the next 3 mo(2tabs po bid), then secondary prevention(2tabs/d) for life long or until CD4>200cells/mCL If the candidiasis is not solved with miconazole for 2 wks then consider fluconazole 400mg loading the 200mg/d for 14-21 days +oral hygiene with lemon juice wash Omeperazole 20mg po bid for 14 days Plasil 10mg po PRN # 10 tabs 5/3/2012

Follow up Plan:

Follow up Plan Clinical evaluation include inquiry into possible ARV side effects Include assessment of adherence (>90%), initiation of any interventions and life style modification at least every- 3-month basis (1 st 2years)/After 2yr, if stable,Q6mo Observe for clinical resolution of toxo and fungal manifestations

PowerPoint Presentation:

5/3/2012 Laboratory monitoring of patients on HAART: CD4 cell count/%: 3 and 6 months post-initiation, then every 6 months (all ages) Viral load: 3 and 6 months post-initiation, then as follows: (Every 6 months for adults)

PowerPoint Presentation:

5/3/2012 AST/ALT : NVP-based HAART : 2, 4, and 12 weeks post-initiation, thereafter only as clinically indicated Creatinine and creatinine clearance: 3 and 6 months post-initiation and then, if stable, every 6 months ( TDF only )

Patient education points:

Patient education points Pts should wash their hands after touching uncooked or undercooked meat should wash vegetables and fruits before consumption and should eat only properly cooked meat. 5/3/2012

PowerPoint Presentation:

5/3/2012 patients should avoid contact with any material that could be contaminated with cat feces and use gloves when cleaning cat litter boxes or when gardening. All patients diagnosed with HIV should be educated about primary and secondary medical prophylaxis for T. gondii infection.

PowerPoint Presentation:

5/3/2012 Once started, HIV treatment is usually lifelong. Patient must take his/her medicines regularly. Patient should also be informed that, taking a "break" from treatment can significantly increase the patient risk of developing drug resistance or opportunistic infections. Pt should also informed about possible S/Es

References :

References Joseph T. DiPiro , P., FCCP; Executive Dean and Professor, South Carolina College of Pharmacy, University of South Carolina, Columbia, South Carolina and Medical University of South Carolina, Charleston, South Carolina (2008). Pharmacotherapy A Pathophysiologic Approach, McGraw-Hill. David K McCulloch, M. (2011). Overview of medical care in adults with diabetes mellitus. UPTODATE DESKTOP M. David M Nathan. 19.1. 5/3/2012

PowerPoint Presentation:

5/3/2012 John G. Bartlett(2003). Medical Management of HIV infection. Johns Hopkins University . Mary Anne Kodda kible, Applied therapeutics ; the clinical use of drugs (2009). 9 th edition John G. Bartlett(2003). Medical Management of HIV infection. Johns Hopkins University . Harrison. Harrison's Principles of Internal Medicine. 18 ed. al Le, editor2010. Uptodate 19.2

Questions?:

Questions?

PowerPoint Presentation:

Thank you