CASE OF AN HIV PATIENT

GENERAL OVERVIEW OF HIV/AIDS

HIV stands for Human Immunodeficiency Virus, a pathogen that works by attacking the human
immune system. It belongs to a class of viruses called retroviruses and more specifically, a
subgroup called lentiviruses, or viruses that cause disease slowly.

HIV cannot replicate on its own, so in order to make new copies of itself, it must infect cells of
the human immune system, called CD4 cells. CD4 cells are white blood cells that play a central
role in responding to infections in the body.

Over time, CD4 cells are killed by HIV and the body’s ability to recognise and fight some types
of infection begins to decline. If HIV is not controlled by treatment, the loss of CD4 cells leads
to the development of serious illnesses, or ‘opportunistic infections’. In people with normal CD4
cell levels, these infections would be recognised and cleared by the immune system.

HIV is called a retrovirus because it works in a back-to-front way. Unlike other viruses,
retroviruses store their genetic information using RNA instead of DNA, meaning they need to
‘make’ DNA when they enter a human cell in order to make new copies of themselves.

HIV is a spherical virus. The outer shell of the virus is called the envelope and this is covered in
spikes of the ‘glycoproteins’ gp120 and gp41, which allow HIV to lock onto the CD4 receptor on
CD4 T cells and enter the cell.

Human immunodeficiency virus (HIV) is a blood-borne virus typically transmitted via sexual
intercourse, shared intravenous drug paraphernalia, and mother-to-child transmission (MTCT),
which can occur during the birth process or during breastfeeding. HIV disease is caused by
infection with HIV-1 or HIV-2, which are retroviruses in the Retroviridae family, Lentivirus
genus.HIV produces cellular immune deficiency characterized by the depletion of helper T
lymphocytes (CD4+ cells). The loss of CD4+ cells results in the development of opportunistic
infections and neoplastic processes.When the immune system is damaged enough that significant
opportunistic infections begin to develop, the person is considered to have AIDS.A CD4+ T-cell
count less than 200/µL is also used as a measure to diagnose AIDS.AIDS manifests as recurrent,
severe, and occasionally life-threatening infections and/or opportunistic malignancies.The signs
and symptoms are those of the presenting illness, meaning that HIV infection should be
suspected as an underlying illness when unusual infections present in apparently healthy
individuals.HIV infection can cause some sequelae, including AIDS-associated
dementia/encephalopathy and HIV wasting syndrome (chronic diarrhea and weight loss with no
identifiable cause)

The signs and symptoms of include:

● Soaking night sweats

● Recurring fever
● Chronic diarrhea
● Persistent white spots or unusual lesions on your tongue or in your mouth
● Persistent, unexplained fatigue
● Weight loss
● Skin rashes or bumps

PHASES OF HIV INFECTION

Clinical HIV infection undergoes 3 distinct phases: acute seroconversion,

asymptomatic infection, and AIDS Acute seroconversion
During this phase, the infection is established and a proviral reservoir is created. This reservoir
consists of persistently infected cells, typically macrophages, and appears to steadily release
virus. Some of the viral release replenishes the reservoir, and some goes on to produce more
active infection.
The proviral reservoir, as measured by DNA polymerase chain reaction (PCR), seems to be
incredibly stable. Although it does decline with aggressive antiviral therapy, the half-life is such
that eradication is not a viable expectation.
The size of the proviral reservoir correlates to the steady-state viral load and is inversely
correlated to the anti-HIV CD8+ T-cell responses. Aggressive early treatment of acute infection
may lower the proviral load, but generally, treatment in newly infected (but postseroconversion)
patients yields no long-term benefit.
At this point, the viral load is typically very high, and the CD4+ T-cell count drops precipitously.
With the appearance of anti-HIV antibodies and CD8+ T-cell responses, the viral load drops to a + T-
cell count returns to levels within the reference range, although steady state and the CD4
slightly lower than before infection.
Seroconversion may take a few weeks, up to several months. Symptoms during this time may
include fever, flulike illness, lymphadenopathy, and rash. These manifestations develop in
approximately half of all people infected with HIV.
Asymptomatic HIV infection
At this stage in the infection, persons infected with HIV exhibit few or no signs or symptoms for
a few years to a decade or more. Viral replication is clearly ongoing during this time, and the
immune response against the virus is effective and vigorous. In some patients, persistent
generalized lymphadenopathy is an outward sign of infection. During this time, the viral load, if
untreated, tends to persist at a relatively steady state, but the CD4+ T-cell count steadily declines.
This rate of decline is related to, but not easily predicted by, the steady-state viral load. No firm
evidence has shown that the initiation of therapy early in the asymptomatic period is effective.
However, very late initiation is known to result in a less effective response to therapy and a
lower level of immune reconstitution.
AIDS
When the immune system is damaged enough that significant opportunistic infections begin to
develop, the person is considered to have AIDS. For surveillance purposes in the United States, a
CD4 opportunistic infections develop when CD4+ T-cell count less than 200/µL is also used as a
measure to diagnose AIDS, although some+ T-cell counts are higher than 200/µL, and some
people with CD4 counts under 200/µL may remain relatively healthy.

Many opportunistic infections and conditions are used to mark when HIV infection has
progressed to AIDS. The general frequency of these infections and conditions varies from rare to
common, but all are uncommon or mild in immunocompetent persons. When one of these is
unusually severe or frequent in a person infected with HIV and no other causes for immune
suppression can be found, AIDS can be diagnosed.

MANAGEMENT

Effective antiretroviral therapy is the most important intervention in terms of improving

longevity and preventing opportunistic infections in patients with human immunodeficiency
virus (HIV) infection. Therapy should involve combinations of drugs recommended by current
guidelines.Highly active antiretroviral therapy (HAART) is the principal method for preventing
immune deterioration. Classes of antiretroviral agents include the following:
 ● Nucleoside reverse transcriptase inhibitors (NRTIs)
● Protease inhibitors (PIs)
● Non Nucleoside reverse transcriptase inhibitors (NNRTIs)
● Fusion inhibitors
● CCR5 co-receptor antagonists (entry inhibitors)
● HIV integrase strand transfer inhibitors
● Entry inhibitors (CD4-directed post-attachment inhibitors)

Regimen selection is individualized on the basis of the following :

● Virologic efficacy
● Toxicity
● Pill burden
● Dosing frequency
● Drug-drug interaction potential
● Drug resistance testing results
● Comorbid conditions

Treatment of opportunistic infections is paramount and should be directed at the specific

pathogen,aggressive treatment of life-threatening or otherwise serious infections may necessitate
a temporary stay of antiretroviral therapy to avoid drug interactions or cumulative toxicity.In
December 2012, the FDA approved crofelemer for the relief of diarrhea in patients with
HIV/AIDS who are undergoing antiretroviral therapy.However, before patients are treated with
this drug, they should be properly tested to confirm that the diarrhea is not caused by an infection
or gastrointestinal (GI) disease.

Introduction
Patient I.B is a 25 year old woman with complicated RVD(sepsis, pelvic inflammatory
disease,gastroenteritis,candidiasis, scabies and nephropathy). She was admitted on 30/07/19
upon referral from the HIV clinic as an emergency. Her chief complaints were coughing for the
past 3 weeks, lower abdominal pain, diarrhea, yellowish green vaginal discharge,weight loss and
body rashes.
Vital signs:
BP: 120/60mmHg
PR: 134bpm

SUBJECTIVE DATA
Demographics
● Age: 25 years
● Marital status: single
● Address: Akwa ibom
● Occupation: Hair stylist
● Religion: Christian
Chief complaint 30/7/19
● Yellowish green vaginal discharge
● Body rashes
● Lower abdominal pain
● Severe weight loss
● Diarrhea
● Productive cough with whitish sputum (3 weeks)
● Fatigue
● Malaise
31/07/19
● Cough (3 weeks)
● Chest pain
● Fever
● Offensive vaginal discharge
1/8/19
● Lower abdominal pain
● Recurrent vaginal discharge
● Generalized pain
 ● Vomiting (6/7)
2/8/19
● Vomiting (1/52)
● Diarrhea (1/52)
● Cough
3/8/19
● Patient seen, no complaint
4/8/19
● Patient was not seen
5/8/19
● Persistent vomiting
● Productive cough
● Itchy skin lesion
● Heartburn
6/8/19
● Patient was not seen
7/8/19 - 19/08/19
● Patient seen, no complaint

History of present illness:

● Patient I B was apparently healthy until 7 months ago when she tried to terminate a
pregnancy with herbal remedies, she developed a yellowish green vaginal discharge with
abdominal pain and weight loss that progressively increased severity.
● She developed generalized body rash 3 months ago after a visit to a friend with similar
rash(itchy with dark spots).
● Prior to her visit to the hospital(1/7)she developed severe weakness, diarrhea and
productive cough with whitish sputum

Past medical history:

 ● Patient I.B is a known RVD patient diagnosed 4 years ago while she was 4 months
pregnant.
● She commenced HAART but defaulted one year after and hasn’t been on her drug till
now.

Home medication
● Nil

Social history:
● She is the first child of her mother in a polygamous family with 8 children from 2 wives
● She takes alcohol occasionally but does not consume tobacco
● Her mother is late
● She has a male child who has been fully immunized
● She is aware of contraceptives and uses condoms but she is not aware of pap smear.

Family history
● No history of RVD
Review of systems
Eye Nil

ENT(ear,nose and throat) Nil oral thrush

Respiratory Productive cough with whitish sputum

Gastrointestinal Abdominal pain

Genitourinary Yellowish green vaginal discharge with foul

smell

Musculoskeletal Pain

Integumentary Generalized body rash

 Neurological Nil

Psychiatric Nil

Constitutional symptoms Weight loss

Fever
Fatigue
Night sweat

Allergies
● No known allergies
Pertinent psychosocial issues
● Patient I.B is non adherent to her medication

OBJECTIVE DATA
Vital signs
Date Temp (℃) BP(mmHg) PR(bpm) RR(cpm)

30/07/19 - 120/60 134 -

31/07/19 - 100/60 104 24

01/08/19 - 110/60 100 24

02/08/19 - 80/50 110 30

03/08/19 - 110/70 98 24

04/08/19 - - - -

05/08/19 - - - -

06/08/19 - - - -
 07/08/19 - 100/70 96 24

08/08/19 - 120/60 100 26

09/08/19 36 100/70 98 -

10/08/19 - - - -

11/08/19 - - - -

12/08/19 - - - -

13/08/19 - - - -

14/08/19 - 110/70 104 -

15/08/19 - 100/60 88 -

16/08/19 - 100/60 90 -

17/08/19 - - - -

18/08/19 - - - -

19/08/19 - 100/70 80 -

Physical exam
30/07/19
 ●
●
Chronically ill looking girl
Generalized hyperpigmentation with purpurea skin lesion
● Anicteric
● Pale with dehydration
● No pedal edema
05/08/19
● Acutely ill looking
● Afebrile
● Pale
09/08/19
● Not dehydrated
● Nil pedal edema
● Pale
14/08/19
● Pale
● Afebrile
● Acyanosed
● Nil pedal edema
● Hyperpigmented
Pertinent lab values
1/08/19
● Ultrasound - Bilateral nephropathy grade 3 with associated findings of hepatomegaly.
7/08/19
● CD4 count: 78cells/mm³
● WBC: 6.7 x 10⁹/L
● SCr: 158µmol/L

●
 ●
●
Diagnostics 30/07/19
Advanced RVD not on HAART
Do m/c/s
Do FBC
31/07/19
● Sepsis due to gastroenteritis
● Urogenital infection
● Candidiasis/PID
● Advanced RVD
● Send to gynaecological team
01/08/19
● RVD with complication
● Sepsis (PID & CKD)
● Bilateral nephropathy grade 3
● Do FBG
02/08/19
● RVD with complication
● Gastroenteritis
● Upper GI bleeding
● Scabies
● Nephropathy
● Do S/E/U/Cr, FBC, PSR, blood film, urinalysis, urine m/c/s, vaginal swab m/c/s, CD4
count, viral load. 5/08/19
● Do chest x-ray,sputum AFB

●
 ●
●
Current medication
31/07/19
● IV Ceftriaxone 1g 12hrly for 48 hours
● IV Flagyl 500mg 8hrly for 48 hours
● Dextrose saline IVF 1liter 8hrly for 48 hours
KIV: blood transfusion
Tab Coartem 80/480mg bd x 3/7
Tab Paracetamol 1g tds x 3/7
1/08/19
● IV 5% dextrose saline 1liter 8hrly x 5/7
● IV Vitamin B complex 5mls
● IV Rocephin 1g bd x 5/7
● IV metronidazole 500mg 8hrly x 5/7
● Caps astyfer 2/08/19
● IV levofloxacin 500mg 12hrly x 3/7
● 5% dextrose 1liter 8hrly x 72hours,add 10ml vitamin b complex in each liter
● Tab omeprazole 20mg bd x 5/7
● 4 tabs Ivermectin stat
● Tab albendazole 400mg 1daily x 1/52 5/08/19
● Levofloxacin 500mg bd x 1/52
● Ivermectin 400mg
● Albendazole 400mg daily x 1/52
● Tab astyfer 1 daily x 2/52
● Loratadine 10mg bd x 5/7
● Consult HIV clinic 07/08/19
● Omeprazole 40mg bd x 5/7 08/08/19

●
 ●
●
● Group matching/cross matching 3 units of blood and transfuse under furosemide
● 1 unit of fresh whole blood daily x 3/7
● Tab azithromycin 500mg daily x 1/52
09/08/19
Tab septrin 960mg daily

●
 ●

Remind HIV clinic to review patient relative to ART 15/08/19

● Transfuse blood 16/08/19
● Continue other management
19/08/19
● Continue other management

ASSESSMENT
Rationale for drug therapy
● Ceftriaxone and metronidazole was used to treat pelvic inflammatory disease. For
inpatients CDC treatment regimen consists of cefoxitin 2g IV every 6 hours and
doxycycline 100mg oral or IV. Ceftriaxone was used for the treatment of gastroenteritis
● Ivermectin is used to treat scabies in immunocompromised patients.it is given 200µg/kg
as a single dose and may be repeated after 14days.the dose of ivermectin given is wrong.
● Coartem was given as an empirical treatment for malaria since it is a malaria endemic
area.
● Paracetamol was given for pain reduction.
● Vitamin b complex helps to prevent infections and helps support or promote cell health.
● Septrin was given for the productive cough and urinary tract infection.
● Loratidine was given for the itchy skin.
● Astyfer is a multivitamin and iron product used to treat or prevent vitamin deficiency due
to poor diet or certain illnesses.
● Omeprazole was given for ulcer and heartburn.
● IV fluid was given for dehydration due to fluid and electrolyte loss by diarrhea and
vomiting.
Unnecessary drugs
● Levofloxacin is an unnecessary antibiotic
Albendazole is an unnecessary drug since she doesn't have any worm infestation
Additional drugs
● No drug was prescribed for candidiasis. Fluconazole 150mg should be given

●
 ● Patient should be given plasil for the persistent vomiting
● Suitable HAART regimen should be commenced as soon as possible,also noting the first
line drug she has failed to avoid adding it to the second line combination.
PLAN
● Withdraw levofloxacin
● Withdraw albendazole
● Add fluconazole 150mg
● Add tab plasil 10mg daily
● Suitable HAART regimen should be commenced as soon as possible,also noting the first
line drug she has failed to avoid adding it to the second line combination.
● Do chest x-ray and sputum AFB
● Do pap smear
EDUCATION
● Encourage and counsel patient against depression.
● Advise patient to adhere to ARV medications,and educate the patient on the benefits of
HAART and consequences of failure to the second line of HAART
● Advise patient on eating healthy and living a healthy lifestyle by eating more fruits and
vegetables
● Educate patient on the side effects of ARV medications

REFERENCES
1. Michael B.S , HIV Infection and AIDS;
 https://emedicine.medscape.com/article/211316-overview
2. https://mayoclinic.org/diseases-conditions/hiv-aids/symptoms-causes/syc-20373524