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CASE 4

CASE 4. 67 yo man HIV+ 1991 Hypertensive CD4 on diagnosis 110/7% AZT initiated soon after diagnosis. CASE 4. Antiviral History. CASE 4. 2011 Referred for 2 distinct episodes (2008, 2011) of 5kg weight loss/profound fatigue and pancytopenia lasting 4-8 weeks each time. CASE 4. CASE 4.

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CASE 4

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  1. CASE 4 • 67 yo man • HIV+ 1991 • Hypertensive • CD4 on diagnosis 110/7% • AZT initiated soon after diagnosis

  2. CASE 4 Antiviral History

  3. CASE 4 2011 • Referred for 2 distinct episodes (2008, 2011) of 5kg weight loss/profound fatigue and pancytopenia lasting 4-8 weeks each time

  4. CASE 4

  5. CASE 4 2011 CT abdomen • normal liver • Spleen 16 cm • No nodes • Spleen size unchanged from 2004 U/S CT chest • normal

  6. CASE 4 2011 Bone MarrowAspirate/Biopsy • Normal progenitors for all cell lines with no evidence of malignancy • Compatible with peripheral destruction/sequestration

  7. CASE 4 2011 • Noted that both episodes of constitutional symptoms occurred in temporal relationship to the initiation/reinitiation of Eprosarten therapy for hypertension • This medication was discontinued without further recurrence of symptoms over the next 2 years

  8. CASE 4 2011-13 • Blood counts recovered though platelets remained lower than previous

  9. CASE 4

  10. CASE 4 2012 • Required a laparoscopic cholecystectomy and intra-operatively liver noted to be “coarse/nodular”

  11. CASE 4 No ETOH – significant previous history x 20 yrs HCV RNA/HBV DNA (-) secondary liver disease workup (-)

  12. CASE 4 • Fibroscan done…. 32.8 kpa! • U/S • No varices • +Ascites • Liver 18.7 c.m/nodular contour • Spleen 18.9 cm • Normal portal/hepatic veins

  13. CASE 4 Transjugular liver biopsy performed • F2-3 scarring from steatohepatitis • Venous/sinusoidal pressures compatible with nodular regenerative hyperplasia or non cirrhotic portal hypertension • OGD…no varices • Ascites managed with diuretics

  14. CASE 4 Take home message… • Low platelets, which have a very long differential diagnosis in the context of HIV, can be a clue to occult severe liver disease…ie. cirrhosis with portal hypertension, or far more rarely, non cirrhotic portal hypertension

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