1 / 21

Mr X and Mr Y

Case 4: July 2007. Mr X and Mr Y. Case 4: July 2007. 26 year-old Caucasian man ‘Mr X’. Case 4: July 2007. Presents to ED at 18:00 with: 1-day history of: maculopapular rash to chest, face, arms and legs 3-day history of: headache neck stiffness photophobia diarrhoea and vomiting

brent
Télécharger la présentation

Mr X and Mr Y

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Case 4: July 2007 Mr X and Mr Y

  2. Case 4: July 2007 • 26 year-old Caucasian man • ‘Mr X’

  3. Case 4: July 2007 Presents to ED at 18:00 with: 1-day history of: • maculopapular rash to chest, face, arms and legs 3-day history of: • headache • neck stiffness • photophobia • diarrhoea and vomiting • arthralgia

  4. Case 4: July 2007 OE: • Pyrexia 39.8oC • Maculopapular rash over face, chest, limbs • Photophobic, no overt meningism • Routine bloods unremarkable • CT head / LP NAD • Treated to cover bacterial meningitis • Clinically improved and discharged home • No HIV test performed

  5. Case 4: July 2008 • 25 year-old British gay male • ‘Mr Y’

  6. Case 4: July 2008 Presents to ED with: • Headache • Neck stiffness • Fever • Maculopapular rash on face, chest, limbs • Nausea, vomiting • Cervical lymphadenopathy

  7. Case 4: July 2008 History: • Last sexual contact: • Regular Male Partner of 3 months (no condoms) • Previous contacts: • Casual Male Partner 5 months ago (condoms) • Casual Male Partner 8 months ago (condoms) • HIV-1 antibody test negative 3 months earlier

  8. Case 4: July 2008 Investigations: • Routine bloods unremarkable • HIV-1 antibody: weakly positive • HIV-1 antibody (detuned): suggestive of infection within 6 months • HIV RNA viral load 1,000,000 copies/ml • CD4 count 699 (9%)

  9. Case 4: summary • Both: viral type illness with meningism and rash • Mr Y’s Regular Male Partner of 3 months = Mr X • Mr X now tests positive for HIV Diagnoses: Mr Y: HIV seroconversion Mr X: ??HIV seroconversion

  10. Q: When could HIV testing have been recommended in this scenario? • When Mr X was admitted with aseptic meningitis without any apparent risk factors? • When Mr Y was admitted with aseptic meningitis with a history of sex with other men? • Should they have been referred on discharge to GUM to see a trained counsellor before HIV testing?

  11. Who can test?

  12. Who can test?

  13. Who to test?

  14. Who to test?

  15. Who to test?

  16. Q: What kind of tests should have been used to diagnose seroconversion illness? • Rapid test? • 3rd generation antibody test? • 4th generation antigen/antibody test? • PCR (viral load)?

  17. Which test to use?

  18. Case 4: summary • Both: viral type illness with meningism and rash • Mr Y’s Regular Male Partner of 3 months = Mr X • Mr X now tests positive for HIV Diagnoses: Mr Y: HIV seroconversion Mr X: ??HIV seroconversion Was Mr Y’s HIV infection preventable?

  19. Learning Points • Primary HIV Infection is easily missed – have a low index of suspicion on presentation of PUO, meningism and rash in adults • During PHI viral load is extremely high making the patient highly infectious • Some patients may not disclose that they have put themselves at risk of HIV infection in the past • A perceived lack of risk should not deter you from offering a test when clinically indicated

  20. Key messages • Antiretroviral therapy (ART) has transformed treatment of HIV infection • The benefits of early diagnosis of HIV are well recognised - not offering HIV testing represents a missed opportunity • UK guidelines recommend universal HIV testing for patients from groups at higher risk of HIV infection • Primary HIV Infection is a unique opportunity to diagnose HIV as the patient’s next HIV-related presentation may be at a late stage of infection

  21. Also contains UK National Guidelines for HIV Testing 2008 from BASHH/BHIVA/BIS Available from: enquiries@medfash.bma.org.uk or 020 7383 6345

More Related