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CASE 2

CASE 2. 54 yo man…HIV + 1997 PCP Cryptospordiasis Chronic HepC Genotype 1a Biopsy… 2/4 activity, 3/4scarring CD4 40 No baseline genotype. CASE 2. 1998-2002 D4T/3TC/Indinavir initiated CD4 30 → 400 Viral load undetectable. CASE 2. U/A - ++ WBC + IDV crystals

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CASE 2

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  1. CASE 2 • 54 yo man…HIV+ 1997 • PCP • Cryptospordiasis • Chronic HepC • Genotype 1a • Biopsy… 2/4 activity, 3/4scarring • CD4 40 • No baseline genotype

  2. CASE 2 1998-2002 D4T/3TC/Indinavir initiated • CD4 30 → 400 • Viral load undetectable

  3. CASE 2 • U/A - ++ WBC + IDV crystals • Creatinine – 80 → 115 • Indinavir crystal induced interstitial renal disease felt to be responsible

  4. CASE 2 2002-2008 • D4T/3TC/Nelfinavir • Mild intermittent diarrhea • Successfully treated for Hepatitis C with 48 wks of Peg Interferon/RBV • CD4 450-700 VL <50

  5. CASE 2 2008 • D4T/3TC/Nelfinavir • Ongoing diarrhea • Increasing recognition of dorsocervical fat pad • Switched to TDF/FTC/Efavirenz

  6. CASE 2 WHAT WOULD YOU DO?

  7. CASE 2 June 2009 • TDF/FTC/Efavirenz switched to TDF/FTC/Etravirine to attempt to r/o Efavirenz as cause of hepatitis

  8. CASE 2 WHAT WOULD YOU DO?

  9. CASE 2 • TDF/FTC/Etravirine switched to D4T/3TC/Etravirine to attempt to r/o TDF/FTC as rare cause of hepatitis

  10. CASE 2 Sept/09 D4T/3TC/Etravirine WHAT WOULD YOU DO?

  11. CASE 2 • Switched back to TDF/FTC/Etravirine as patient concerned about lipodystrophy and unclear whether liver improving at all from Etravirine or TDF/FTC switch

  12. CASE 2 WHAT IS HAPPENING? WHAT WOULD YOU DO?

  13. CASE 2 • Patient self-discontinues meds

  14. CASE 2 • Restarted TDF/FTC/Efavirenz for simplicity/convenience NOW WHAT?

  15. CASE 2 Late September 2010 • Switched to D4T/3TC/Raltegravir as previously had normal liver enzymes for years on D4T/3TC/Nelfinavir and need to get rid of TDF/FTC and NNRTI class. • Refused PI due to lipohypertrophy STAY TUNED!!!

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