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Transcript
Prolonged Fever and Wasting Syndrome HAIVN Harvard Medical School AIDS Initiative in Vietnam 1 Learning Objectives By the end of this session, participants should be able to: Outline causes of fever in an HIV patient Describe causes of wasting syndrome in an HIV patient Explain the process for diagnosing, testing and treating prolonged fever and wasting 2 What is the Definition of “Prolonged Fever”? Who is at Risk? 3 Overview of Prolonged Fever in PLHIV (1) Fever over 38.5 C lasting for more than 14 days without any determined cause • Common in PLHIV, particularly those with advanced disease • If the CD4 count is low, more than one infection or process may be present • High grade fevers with other symptoms are often due to another process, not HIV itself 4 Overview of Prolonged Fever in PLHIV (2) Factors influencing initial differential diagnosis of fever: • • • • • • • CD4 count/WHO staging Course (acute vs. chronic) Common OIs in the region Patient’s personal OI history Infections in selected population (i.e. IDU) Localizing signs and symptoms ARV (risk for IRIS) 5 Fevers in HIV Patients: Infectious and Non-Infectious Etiologies Category Type Etiology Most Common Infectious Etiologies Mycobacterial • TB Fungal • Penicilliosis • Cryptococcosis Bacterial • Salmonellosis Parasitic • Toxoplasmosis • Malaria Neoplasia • Lymphoma Miscellaneous • Drug reaction 6 • IRIS NonInfectious Etiologies Differential Diagnosis by CD4 John Bartlett, Medical management of HIV Infection, 2004 CD4 <50 • • • • TB Penicillium marneffei Disseminated MAC CMV (retinitis, colitis, esophagitis) CD4 < 100 • • • • TB Toxoplasmosis Cryptococcosis Histoplasmosis CD4 < 200 • TB • PCP CD4 >200 • TB • Bacterial infections, especially Strep pneumonia 7 Approaching a Patient With Fever and HIV (1) When a PLHIV presents with fever providers should: • Take a history • Perform a physical examination • Conduct baseline tests Taking a thorough history and conducting a physical exam give important clues about the diagnosis 8 Approaching a Patient With Fever and HIV (2) What should providers look for when taking a patient history and conducting the physical exam? 9 History When taking a history it is important to find out about: Category Specifics Fevers: • • • • • Localizing symptoms: Duration Pattern Grade Pain Headache General symptoms: • Weight loss • Night sweats Associated information: • History of OIs • Drug use • Sexual history, etc 10 Physical Examination Gen Skin HEENT Lymph nodes Lungs Heart cachexia rash, skin lesions oral lesions enlarged LN, including cervical, axillary, inguinal regions tachypnea, abnormal lung sounds tachycardia, distant heart sounds, murmurs Abdomen hepatosplenomegaly, ascites Neuro focal neurological deficits, altered mental 11 status Baseline Tests Some of the most common tests include: CBC, chemistries, liver function tests CD4 count CXR and sputum smear for AFB x 3 Fine needle aspiration of lymph node Blood cultures Urinalysis 12 Empiric Treatment (1) Empiric treatment = treatment before making a definite diagnosis Treat with antibiotics for common OIs or according to symptoms Avoid quinolones if TB is a consideration • Monotherapy partially treats TB and MAC, making diagnosis more difficult and resistance more likely 13 Empiric Treatment (2) If patient improves, continue treatment If no improvement: • RE-EVALUATE to look for new signs or symptoms • Repeat tests and cultures • Repeat AFB smears if TB possible • Consider ARV (if indicated) 14 Supportive Treatment Treat fever with paracetamol or NSAIDS If dehydration present: give IV fluids until patient able to take oral hydration Adequate nutrition ARV may be best treatment if: • work-ups negative, and • patient not improved on empirical treatment (beware of risk of IRIS) 15 Group Activity: Review of Algorithm for Diagnosis and Treatment of PLHIV 16 Wasting Syndrome 17 AIDS Wasting Syndrome: Definition Involuntary loss of more than 10% of body weight, plus more than 30 days of either diarrhea, or weakness and fever In the absence of another illness or condition other than HIV infection that could explain the findings Source: US Centers for Disease Control (CDC) 18 18 AIDS Wasting Syndrome 19 Group Brainstorm: What are some of the causes of wasting in PLHIV? 20 Etiology (1) Low food intake: Category Symptom Low appetite • drugs have to be taken with an empty stomach Drug side effects • nausea • changes in the sense of taste OIs in mouth or • painful to eat throat Lack of money or • may make it difficult to shop energy for food or prepare meals 21 Etiology (2) Poor nutrient absorption: • Many infections interfere with this process • HIV may directly affect intestinal lining • Diarrhea Altered metabolism: • PLHIV need more calories just to maintain body weight 22 Etiology (3) Infection and Malignancy: Category Causes Mycobacteria • TB • MAC Fungi • • • • • • • • • Virus Parasitic diarrhea Tumor P. marneffei Candida esophagitis CMV HIV HSV (esophagitis) Microsporidia Isospora Cryptosporidia Lymphoma 23 Case Presentation A 24 year old man presents with a 4 week history of fever, weight loss and anorexia Recently diagnosed with HIV at the local VCT site He denies any prior illnesses or hospitalizations He takes no medications and has no allergies 24 What Other Information do You Want at This Time? 25 Clues From the History Localizing symptoms Prior illnesses or OIs Reason for testing for HIV • Animals • sick family members • unclean water exposure • due to OI? Sexual history Drug use history Exposures Occupation 26 Case (cont.) Has lost 10 kg over 2 months Cannot eat due to a very sore throat Has no headache, diarrhea, abdominal pain, cough or shortness of breath Has not traveled Has not worked for past 4 weeks • previously worked as a motorbike repairman Denies any IDU 27 Case (cont.): Physical Exam Findings Vital signs: normal General: cachetic Oropharynx: thrush present LN: bilateral cervical and axillary lymphadenopathy (1-5 cm). Skin: no rash The rest of the exam is normal 28 Case (cont.): Initial Laboratory Results Hct: 28% WBC: 4,200 (10%lympho) LFTs: ALT 65, AST 60 Urinalysis: negative CXR: very small left pleural effusion otherwise negative Sputum BK: negative X 3 CD4 count: 70 29 What is Your Initial Diagnosis? WHO Clinical Stage? • Stage 3 (oral thrush, >10% weight loss) Opportunistic infections? • Oral candidiasis • Possible esophageal candidiasis • Lymphadenopathy (undetermined etiology) Other diagnoses? • Anemia 30 What is the Cause of the Fever and Lymphadenopathy? Consider these factors in your differentials: • WHO staging/CD4 • Oral and esophageal candidiasis are indications of poor immune function, but do not usually cause fever or lymphadenopathy Think of common OIs in VN: • TB, TB, TB • Then fungi or bacteria • MAC (incidence is unknown in VN) 31 Lymphadenopathy Localized, usually unilateral: Tuberculosis MAC Cryptococcus P. marneffei Bacteria (Staphylococcus aureus, anaerobes) Non-Hodgkin lymphoma Generalized, multiple: HIV Tuberculosis MAC (rare) Syphilis Non-Hodgkins lymphoma Kaposi Sarcoma 32 If No Localizing Symptoms Blood culture for bacteria, fungus, AFB Biopsy of lymph nodes (if present) Abdominal ultrasound may show intra-abdominal lymph nodes or hepatic/splenic enlargement 33 Case (cont.) What would you do next? • The patient had an aspiration of the axillary lymph node • BK stain: positive What does that mean? • He has TB • He was started on 4 drugs for TB and is now doing well 34 Key Points Fever is common in HIV patients Prolonged fever may indicate an underlying infectious etiology • Appropriate work-ups should be done • Empiric treatment can be given if no definite diagnosis is made • Patients with negative work-ups should be re-evaluated with repeat clinical exams and diagnostic testing Most common cause of prolonged fever and wasting is TB 35 Thank you! Questions? 36