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VIRTUAL MEDZONE

This case presentation discusses a 59-year-old male patient with a long-standing HIV diagnosis who presented with bilateral rib, leg, and foot pain, muscle weakness, and fatigue. Despite being asymptomatic with a normal CD4 count, further investigations revealed hypophosphatemia and elevated ALP isoenzymes, suggesting osteomalacia due to Fanconi syndrome. After discontinuing Tenofovir and modifying the antiretroviral regimen, alongside supplementation with potassium phosphate and vitamin D, the patient showed significant improvement in symptoms. This case emphasizes the need for vigilant monitoring and individualized treatment in HIV patients.

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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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