Case presentation 22-Nov-18 OT-PT 02 Mar 2007

36 year old single man, living alone, successful graphic artist 10 year history of injection drug use mostly cocaine (no use since 2006) hepatitis C infection, 1999; hepatitis B immune (post-infection) injection site abscess & ulcer, 2001 humerus fractured, 2002 Bisexual with multiple partners, unprotected intercourse HIV infection discovered, 2001 HAART began (November, 2005) when CD4 = 146 cells/mm3 viral load = 329,000 copies/mL Varicella zoster, 2005 C5-6-7-8 post herpetic neuralgia poor pain control (now on amitryptiline + methadone) 22-Nov-18 OT-PT 02 Mar 2007

Examples of injection site abscesses and ulcers 22-Nov-18 OT-PT 02 Mar 2007

Humerus fracture 22-Nov-18 OT-PT 02 Mar 2007

Varicella zoster infection, right arm 22-Nov-18 OT-PT 02 Mar 2007

HAART safety AZT, 3TC, lopinavir, ritonavir (Combivir & Kaletra) Lots of nausea and mild anemia, so switched, after 3 months, to abacavir + 3TC abacavir hypersensitivity reaction, switched to ddI pancreatitis after 5 months on ddI, switched to d4T d4T peripheral neuropathy (stocking-glove, both feet) d4T stopped; switched to tenofovir (October, 2006) cholesterol increased (9.3 mmol/L), facial lipoatrophy, osteopenia HAART changed to tenofovir, 3TC, efavirenz severe dizziness and feeling “stoned”; nocturnal fall fractures wrist switched from efavirenz to atazanavir boosted with ritonavir ATZ scleral icterus (bilirubin elevated at 94 mmol/L) now, wants a drug holiday…. 22-Nov-18 OT-PT 02 Mar 2007

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Stocking-glove type sensory neuropathy 22-Nov-18 OT-PT 02 Mar 2007

JL Lohan before she fractured her wrist in two places in Sept 2006 22-Nov-18 OT-PT 02 Mar 2007

Colles fracture (#2) 22-Nov-18 OT-PT 02 Mar 2007

Scleral icterus 22-Nov-18 OT-PT 02 Mar 2007

HAART efficacy HIV replication CD4 restoration Viral load dropped from 329,000 c/mL before treatment to <50 c/mL after 3 months of treatment viral load has remained undetectable ever since CD4 restoration CD4 cells have not changed substantially since starting HAART /mm now about 170 cells/mm3 remains on cotrimoxazole, as prophylaxis against PCP 22-Nov-18 OT-PT 02 Mar 2007

What about liver? hepatitis C infection never evaluated before HCV RNA positive; type 1A; viral load = 4.9 million c/mL inflammation mild (AST, ALT increased) synthesis reduced slightly (INR increased) catabolism OK (bilirubin; NH3) biopsy: inflammation with early fibrosis needs treatment = pegylated interferon & ribavirin develops severe depression suicide attempt (no big “sequellae”) messes up meds (stops HAART, cotrimoxazole; pegetron & ribavirin) viral load jumps to 251,000 c/mL, one month later CD4 drop to 133 cells/mm3 hep C still present in blood hepatitis C treatment postponed until depression done HAART restarted after hiatus of two months 22-Nov-18 OT-PT 02 Mar 2007

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Now On HAART regimen for 3 months, cough, dyspnea, 38.6ºC fever but viral load increasing (now 34,215 c/mL) CD4 cells declining (now, 109 cells/mm3) persistent fatigue; night sweats; losing weight cough, dyspnea, 38.6ºC fever interstitial pneumonitis = probable PCP never re-started cotrimoxazole broncoalveolar lavage shows Pneumocystis develops 30% pneumothorax, necessitating chest tube develops nausea and anorexia from high-dose cotrimoxazole begins dapsone but develops hypersensivity reaction PCP finally treated successfully with atovoquone chest tube removed; discharged home 22-Nov-18 OT-PT 02 Mar 2007

Normal chest x-ray on left; Pneumocystis carinii pneumonia on right Normal chest x-ray on left; Pneumocystis carinii pneumonia on right. Note the confluent interstitial pattern in the right upper lobe and the ground glass appearance obscuring the heart border 22-Nov-18 OT-PT 02 Mar 2007

HAART failure Hepatitis C infection Substance use genotyping shows HIV resistant to 3TC, ddI, abacavir, tenofovir lopinavir, ritonavir new regimen started: d4T, 3TC, TMC-114, ritonavir, TMC-125 after 2 months of new HAART regimen viral load undetectable (< 50 c/mL) CD4 increased to 178 cells/mm3 feels well; no side-effects, so far Hepatitis C infection pegetron & ribavirin to be restarted, as soon as HAART stable citalopram started to try to prevent depression Substance use pain control remains a big problem post-herpetic neuralgia HAART/HIV neuropathy old wrist fracture chest pain (chest tube, etc) 22-Nov-18 OT-PT 02 Mar 2007

New problems angina with hypercholesterolemia hip pain renal disease cardiac catheterization: 4 vessel disease; 2 stents placed on waiting list for CABG on lipid-lowering medications on medications to control blood pressure hip pain tests show early aseptic necrosis of left femoral head more pain (partial relief with NSAIDs) activities limited (cane; crutches, sometimes) on waiting list for arthroplasty renal disease multiple causes: HIV; tenofovir; NSAIDs; hypertension; substance use? 3TC dosing changed 22-Nov-18 OT-PT 02 Mar 2007

Coronary artery stent placement via cardiac catheterization 22-Nov-18 OT-PT 02 Mar 2007

Coronary artery bypass grafting Coronary artery bypass grafting. The internal mammary artery can be reditrected to perfuse the heart via a coronary artery, or segments of vessels from the leg (e.g. saphenous vein) can be used as shown here. 22-Nov-18 OT-PT 02 Mar 2007

Avascular necrosis of the femoral head, and replacement of the hip. 22-Nov-18 OT-PT 02 Mar 2007

Five health problems intersect, here: Conclusions Five health problems intersect, here: HIV infection and its diseases HCV infection and its diseases injecting drug use and its complications trauma treatment side-effects and toxicities These problems lead to a variety of transient, chronic and permanent impairments activity limitations participation restrictions 22-Nov-18 OT-PT 02 Mar 2007