CASE 4 67 yo man HIV Hypertensive CD4 on diagnosis 110/7% AZT initiated soon after diagnosis

CASE 4 DATEREGIMENCD4VL AZT AZT/ddI AZT/3TC130< DDI/TDF/RTV/LPV/EFV210< DDI/3TC/RTV/LPV/EFV210< ABC/3TC/RTV/LPV/EFV220< ABC/3TC/RTV/DRV/NVP120<40 Antiviral History

CASE Referred for 2 distinct episodes (2008, 2011) of 5kg weight loss/profound fatigue and pancytopenia lasting 4-8 weeks each time

CASE 4 DATEHBWBCPLTSBone Marrow / Normal progenitor cells 2008/

CASE CT abdomen – normal liver – Spleen 16 cm – No nodes – Spleen size unchanged from 2004 U/S CT chest – normal

CASE Bone Marrow Aspirate/Biopsy – Normal progenitors for all cell lines with no evidence of malignancy – Compatible with peripheral destruction/sequestration

CASE Noted that both episodes of constitutional symptoms occurred in temporal relationship to the initiation/reinitiation of Eprosarten therapy for hypertension – This medication was discontinued without further recurrence of symptoms over the next 2 years

CASE Blood counts recovered though platelets remained lower than previous

CASE 4 DATEHBWBCPLTSBone Marrow / Normal progenitor cells 2008/ Normal progenitor cells

CASE Required a laparoscopic cholecystectomy and intra-operatively liver noted to be “coarse/nodular”

CASE 4 DATEASTALTALKBILIPLTSALBINR No ETOH – significant previous history x 20 yrs HCV RNA/HBV DNA (-) secondary liver disease workup (-)

CASE 4 Fibroscan done… kpa! U/S – No varices – +Ascites – Liver 18.7 c.m/nodular contour – Spleen 18.9 cm – Normal portal/hepatic veins

CASE 4 Transjugular liver biopsy performed F2-3 scarring from steatohepatitis Venous/sinusoidal pressures compatible with nodular regenerative hyperplasia or non cirrhotic portal hypertension OGD…no varices Ascites managed with diuretics

CASE 4 Take home message… Low platelets, which have a very long differential diagnosis in the context of HIV, can be a clue to occult severe liver disease…ie. cirrhosis with portal hypertension, or far more rarely, non cirrhotic portal hypertension