Download Case 36 AIDS with Opportunistic Infections

HIV
CASE 36
ANDREA SIGRIST
PATIENT
Client
• Terry Long
• Sex: Male
• Ethnicity: African
American
• DOB: 5/12
• Age: 32
• Height: 6’1”
• Weight: 151 lbs
Reason for Admittance
• HIV positive (diagnosed
4 years ago)
• Exhausted all the time
• Sore mouth
• Sore throat
• Significant weight loss
• Possible pneumonia
per referring physician
Patient History
Stereopositive for HIV-1,
confirmed by ELISA and
Western Blot 4 years ago
Unknown contraction
Not currently undergoing
treatment
Tonsillectomy at age 6
Appendectomy at age 18
Current medications;
multivitamin, vitamin E,
vitamin C, ginseng, milk
thistle, echinacea
Quit smoking 5 years ago
Family history: father with
angina, heart problems, high
blood pressure (CAD, HTN)
Physical Exam
General Appearance: Thin
African American in no acute
distress
Vitals: Temp 98.6F, BP 120/84,
HR 92bpm, RR 18bpm
Heart: regular rate and rhythm
Nose: Mucosa pink without
drainage
Throat: erythematous with
white, patchy exudate
Extremities: good pulses, no
edema
Skin: warm, with flaky patches
Chest/lungs: Rhonchi in lower
left lung
Abdomen: nondistended,
nontender, hyperactive bowel
sounds
LAB VALUES
Measure
Normal Value
Terry’s Value
Reason for
Concern
Albumin
3.6 – 5
3.6
Low levels are a
sign of malnutrition
Prealbumin
19 – 43
6.0
Low levels are a
sign of malnutrition
Transferrin
200 – 400
17
Low levels are a
sign of malnutrition
Viral Load
0
29000
Elevated levels are
a sign of an
immune disorder
CD4
325 – 997
157
< 200 defines AIDS
BUN
8 – 26
11
Low levels are a
sign of malnutrition
PATIENT DIAGNOSIS AND TREATMENT
DIAGNOSIS
• HIV for four years
• AIDS
• Clinical Cate
• Oral thrush
• No clinical evidence of
pneumonia
TREATMENT
• Antiretroviral regimen
• AZT (zidovudine) 200 mg
every 8hr
• Crixivan (indinavir) 800mg
every 8hr
• 3TC Epivir (lamivudine)
150 mg every 12hr
WHAT IS HIV?
• Infection caused by the human immunodeficiency virus
which destroys the immune system and makes it hard for
the body to fight off infections
• Transmitted through sexual contact, blood, and mother
to child
• People infected may not show symptoms for up to ten
years, but can still infect others
• Progresses to AIDS
• There is no cure, but it can be treated
• People infected with HIV will develop AIDS if not treated
• A small amount of people develop AIDS slowly or not at all
• Is a preventable infection
HIV TESTS
Western Blot
ELISA
• Uses gel electrophoresis
to separate specific
HIV proteins being
detected
• After separation, the
proteins are transferred
to a membrane to be
identified using
antibodies that target
a specific protein
• HIV antigens are added
to a sample of blood and
antibodies react with the
HIV virus
• An enzyme linked to an
antibody is added and
reacts with the HIV
antigen/antibody
• A catalyst is added to
change the color of the
enzyme-linked complex
RISK FACTORS FOR CONTRACTING HIV
Common Risk Factors
• Sexual contact with an
infected person
• Unprotected sex
• Coming in contact with
blood of an infected
person
• Sharing needles
• Blood transfusions
• Mother to child by blood
during delivery or breast
milk
Terry’s Risk Factors
• Worked as a nurse in a
dialysis clinic
• Numerous sexual
partners
• Use of recreational
drugs
PROGNOSIS
• HIV is a chronic condition
• It will eventually completely destroy a person’s immune
system
• Progression depends on each individual
• There are treatment options, but no cure
• Can prevent complications and delay the progression of AIDS
• Almost all people infected will develop AIDS
• Lack of treatment is fatal
• HAART (highly reactive antiretroviral therapy) dramatically
increases how long an infected person lives, but is not a cure
• The weakened immune system makes individuals more
susceptible to infections and cancers
TREATMENT FOR HIV
Treatment
When to Start
• Medications used in
combination is the only
way to control the virus
• It is best to use three
different medications
from two different
classes of drugs to
avoid creating strains
of HIV that are immune
to single drugs
• Symptoms become
severe
• CD4 count is below 500
• Become pregnant
• Have HIV-related
kidney disease
• Being treated for HepC
MEDICATIONS
Types of Medications
• NNRTIs (Non-nucleoside
reverse transcriptase
inhibitors): disables proteins
HIV needs to copy itself
• NRTIs (Nucleoside reverse
transcriptase inhibitors): faulty
versions of building blocks HIV
needs to copy itself
• PIs (Protease Inhibitors):
disable protease , which HIV
uses to copy itself
• Entry or fusion inhibitors: block
HIV’s entry into CD4 cells
• Integrase inhibitors: disables
integrase which HIV uses to
insert genetic material into
CD4 cells
Terry’s Medications
• 200 mg of zidovudine
(AZT) every 8 hours
• 800 mg of indinavir
(Crixivan) every 8 hours
• 150 mg of lamivudine
(3TC Epivir) every 12
hours
SUPPLEMENTS
Supplement
Proposed use in HIV/AIDS
Potential Risk
Vitamin C
Improve antioxidant capacity, increases iron
absorption from non-heme sources
Increases urinary losses of oxalate
and calcium
Vitamin E
Vitamin E may protect against toxicity and side
effects from AZT (antiretroviral medications)
Can interfere with blood clotting.
Cause nausea, diarrhea, muscle
weakness, fatigue
Ginseng
Has anti-stress and anti-fatigue effects; May contain
a protein with anti-HIV activity
morning diarrhea, insomnia,
nervousness, depression,
confusion, skin rashes and high
blood pressure
Milk thistle
May prevent liver damage caused by HIV
medications
Anticancer, immunostimulatory; stimulate immune
system and promote CD4 cell activation
Upset stomach, diarrhea,
bloating, gas
May inhibit metabolism of drugs
using the cytochrome P 450
enzyme pathway
Slows disease progression, increases CD4 count,
lowers viral load values
None
Echinacea
Multivitamin
NUTRITION WITH HIV
Terry’s Diet before Mouth Sores
Suggested HIV Nutrition
• Breakfast/Lunch: 1-2 cups of cold
cereal with ½ cup of whole milk
• Dinner: Meat, potatoes or rice, tea or
soda
• Snacks: Pizza, candy bar, or cookies
with tea or soda
• 1-2 beers or glasses of wine several
times a week
• Consume a healthy and
balanced diet like healthy
individuals
Terry’s 24-hour Diet Recall
Sips of apple juice, 1 cup of yogurt,
1 cup of rice and gravy, sips of
iced tea with sugar throughout the
day
• Calories should be 10% higher
if untreated
• Calories should be 30% higher
during recovery
• Take a daily multivitamin
• If suffering from loss of
appetite:
• Eat several small meals
• Exercise to stimulate appetite
• Consume nutrition supplement
beverage
ALCOHOL AND HIV
• Studies show regular alcohol consumption is
associated with an increase in the progression of
HIV
• The immunosuppressive effects of alcohol may
cause CD4 count to fall below 200 cells
• Still being researched, not a fact
MAIN CONCERNS FOR TERRY
Problems
Suggestions
• Not eating enough
• Consumes a lot of
sugar and soda
• Alcohol consumption
• Not taking medications
• Place on pureed or soft
food diet
• Add nutritional
supplement beverage
• Vegetable juices
• Soy or almond milks
• Educate about
programs that help pay
for medications
GOALS
• Main goal is to get Terry
his medications and
get him taking them
every day as directed
• Educate about healthy
diet and
consequences of
malnutrition and not
taking medications
• Get back on a normal
diet
• Start exercise routine
COURSE OF
ACTION
• Have him meet with a
Medication Assistance
program
• Create diet plan
• Begin with soft/liquid diet
• Progress to normal diet
• Have Terry keep a food
journal
• Join a gym or fitness
group
• Join a support group
QUESTIONS?
REFERENCES
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AIDS.org (2012). AIDS Information, Education, Action, Awareness | How is HIV Transmitted? AIDS Information,
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Boskey, Ph. D., E. (2011, September 6). HIV Testing - How Does a Western Blot HIV Test Work? Sexually Transmitted
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FitDay. (2012). FitDay - Free Weight Loss and Diet Journal. Retrieved from
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Mayo Clinic (2011, August 11). HIV/AIDS: Treatments and drugs - MayoClinic.com. Mayo Clinic. Retrieved from
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Medline Plus (2012, May 30). HIV infection: MedlinePlus Medical Encyclopedia. National Library of Medicine National Institutes of Health. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/000602.htm
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