- Patient presentation
- Differential Diagnosis
- Final outcome
- Evaluation - Questions & answers
- HIV positive 11 years and 10 months old male, vertically infected from his mother.
- WHO stage IV with Immunological stage 3 disease.
- Patient was treated with dual therapy for 1 month and then developed severe gastroenteritis and vomiting.
- Unable to tolerate oral fluids he was admitted to hospital
This case study was kindly provided by Dr Lee Fairlie (nee Kleynhans) MBChB DCH FCpaeds(SA) Wits Paediatric HIV Clinics, Chris Hani Baragwanath Hospital
In March 2006 an 11 years and 9 months old patient presented to private GP after recurrent hospital admissions for pneumonia. At this time he weighed 23 kg (<3rd percentile; 57% expected weight for age) and was classified as wasted.
- CD4=40 (absolute count)
- Normal CXR
- PPD negative
- Sputum AFB’s negative
TB excluded based on these results.
Patient was started on dual therapy:
- AZT 100mg po bd
- 3TC 5ml po bd
GP was already treating mom for HIV with HAART. She was also classified as WHO stage IV with Immunological stage 3 disease and TB was excluded.
- Viral or bacterial gastroenteritis made worse by underlying chronic HIV-related diarrhoea, possible causative organisms include Cryptosporidium parvum/ Giardia lamblia/ Isospora beli.
- Immune Reconstitution Inflammatory Syndrome (IRIS) – based on rapid deterioration after 1 month of starting ART.
- Opportunistic infections such as MAC (Mycobacterium Avium Complex).
- Poor food, drug and nutrient absorption because of HIV related diarrhoea.
- Lactic acidosis (although unlikely because he was not on treatment long enough and AZT does not typically cause this).
- Drug toxicity.
On admission to hospital patient was
- Dehydrated 10%
There was a strong clinical suspicion of hypokalaemia based on:
- Reduced tone, reflexes difficult to elicit.
- Distended abdomen with scanty bowel sounds suggesting a hypokalaemic ileus.
The rest of the examination was non-contributory.
- K+ = 1mmol/L (3.3-5.0 mmol/L)
- Rest of U&E = normal
- Lactate = normal
- Mild transaminitis
Treatment and management
- Patient was admitted to High Care where he was given intravenous potassium
- During his hospital stay he missed ARV’s for 1 day
- After patient’s potassium recovered he was transferred to Hospice for respite care and psychosocial intervention
- In hospice he received nasogastric tube (NGT) feeds in the form of Peptamen, a peptide-based elemental diet for the nutritional support of GI-impaired children. This is absorbed much more easily than food and helps the gut recover, thereby increasing food and drug absorbtion.
- Two months on dual therapy his CD4 count increased to 117 and viral load was undetectable.
The ARVs he was on were noted to be an inadequate dose for the patient:
- AZT – 100mg po bd (inadequate dose, should be 200mg bd for patient’s weight)
- 3TC – 5ml po bd (should have been on 8 ml bd)
- No 3rd drug had been added
Treatment and follow up
At this stage the question was what to do with his ARV’s? Although the therapy he was on was working as evidenced by his climbing CD4 count, suppressed viral load and general health improvement the likelihood of resistance occurring if this is used as long term treatment is high.
The decision was made to start him on triple therapy using corrected dosages appropriate for his body weight. He continued with AZT and 3TC and efavirenz was added to the regimen because his CD4 was improving and he was virally suppressed.
After two weeks he was transferred from Hospice to a hospital close to where his mother works. He has continued with this regimen and he has been followed up regularly.
- His progress has remained very good, his mother is still motivated and compliant and he has continued his triple therapy without interruptions.
- His weight has steadily increased to 34.5 kg (just below 3rd percentile)
- He has been clinically well and has required no intermittent admissions.
- His CD4 count has continued to increase with the last CD4 count at 160 (10.2%)
- Viral load has remained undetectable at < 25 copies
One year later the patient continues to do excellently on triple therapy, he is gaining weight, he has maintained viral load suppression and his CD4 count continues to increase. He is followed up regularly at the same hospital and his mother has remained compliant with his therapy and appears to be compliant with her own therapy too.
Evaluation – Questions & answers
What is the most likely diagnosis for this case?
How does absorbtion of nutrients and drugs occur in a normal functioning Gastrointestinal Tract (GIT)?
How does HIV affect the absorbtion of nutrients and drugs from the GIT?
How does the immune system function in a normal functioning GIT?
How does HIV affect the immune system in the GIT?
What are the benefits of triple therapy over dual therapy?