1. Case presentation
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2. 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 C
post herpetic neuralgia
poor pain control (now on amitryptiline + methadone)
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3. Examples of injection site abscesses and ulcers
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4. Humerus fracture
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5. Varicella zoster infection, right arm
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6. 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….
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8. Stocking-glove type sensory neuropathy
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9. JL Lohan before she fractured her wrist in two places in Sept 2006
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10. Colles fracture (#2)
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11. Scleral icterus
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12. 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
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13. 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
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15. 22-Nov-18
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16. 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
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17. 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
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18. 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)
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19. 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
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20. Coronary artery stent placement via cardiac catheterization
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21. 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.
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22. Avascular necrosis of the femoral head, and replacement of the hip.
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23. 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
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