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VIRTUAL MEDZONE

VIRTUAL MEDZONE. Your Resource for HIV Related Innovative Medical Communication. HIV CASE PRESENTATIONS. Anita Rachlis MD M.Ed FRCPC David Fletcher MD FRCPC. CASE 1. 59 yo man HIV+ since 1994 Asymptomatic CD4 150. CASE 1. Antiretroviral History. CASE 1.

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VIRTUAL MEDZONE

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  1. VIRTUAL MEDZONE Your Resource for HIV Related Innovative Medical Communication

  2. HIV CASE PRESENTATIONS Anita Rachlis MD M.Ed FRCPC David Fletcher MD FRCPC

  3. CASE 1 • 59 yo man • HIV+ since 1994 • Asymptomatic • CD4 150

  4. CASE 1 Antiretroviral History

  5. CASE 1 BASELINE GENOTYPE JUL/03

  6. CASE 1 Apr/2004 • TDF/ABC/RTV/LPV/EFV/Rosuvastatin Feb/2012 • CD4 310 → 670 • VL <40 c/ml

  7. CASE 1 Feb/2012…seen for usual F/U • Six month history of bilateral rib, leg and foot pain along with muscle weakness and fatigue • Exam unremarkable except for very slight proximal muscle weakness WHAT WOULD YOU DO ?

  8. CASE 1 Feb/2012… • CK normal at 43 • Rosuvastatinheld

  9. CASE 1 Mar/2012… No improvement of pain off Rosuvastatin

  10. CASE 1 Mar/2012…further investigations: • CBC normal • Creatinine 135 • U/A… + GLU, 2+ protein • AST 19 ALT 18 ALP 353 CK 43 • Random urine protein 3.325 g/l

  11. CASE 1 Mar/2012

  12. CASE 1 Mar/2012

  13. CASE 1 Mar/2012…further investigations: • Calcium 2.19 PO4 0.58 • Albumin 43 • K+ 3.4 mmole/l, Bicarbonate 20 mmol/l • iPTH 10.7 pmol/l (<6.8 pmol/l=N) • Vitamin D (25HYDR)…42 nmol/l • ANA (-) RF (-) • Fractional excretion PO4..74%

  14. CASE 1 Mar/2012…further investigations: • U/S liver…normal/biliary system normal • HepAIgG/HepB SAB (+) • HepC AB (-) HCV RNA (-) • ALP isoenzymes– bone significantly increased

  15. CASE 1 Mar/2012…further investigations • Xray ribs, knees, ankles & feet…normal • Dexa Scan… Hip t -2.6, L spine t -3.1 • Bone Scan…↑uptake Lt 6th rib, Rt 3rd and 5th rib compatible with fractures

  16. CASE 1 Provisional diagnosis • Osteomalacia 2o hypophosphatemia due to Fanconis syndrome • Tenofovir discontinued and antiretroviral regimen switched to ABC/RTV/DRV/ETR/RGV • Supplemented with potassium phosphate and vitamin D /calcium

  17. CASE 1 Apr/2012…1 month later • Bone pain and muscle weakness have improved dramatically • PO4 0.88 mmole/l Bicarbonate 24 mmole/l K+ 4.2 mmole//l • Awaiting other f/u bloods

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