1. CASE 4 67 yo man HIV+ 1991 Hypertensive CD4 on diagnosis 110/7% AZT initiated soon after diagnosis

2. CASE 4 DATEREGIMENCD4VL 1991-93AZT120------------- 1993-95AZT/ddI110------------- 1995-03AZT/3TC130<500-8453 2003-04DDI/TDF/RTV/LPV/EFV210<50 2004-07DDI/3TC/RTV/LPV/EFV210<50 2007-09ABC/3TC/RTV/LPV/EFV220<50 2009-13ABC/3TC/RTV/DRV/NVP120<40 Antiviral History

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

4. CASE 4 DATEHBWBCPLTSBone Marrow 20051303.0115------------- 20061293.2132------------- 20071222.4113------------- 2008/2851.798Normal progenitor cells 2008/061193.0121-------------- 20091163.0108-------------- 20101323.0119-------------- 2011961.981--------------

5. CASE 4 2011 CT abdomen – normal liver – Spleen 16 cm – No nodes – Spleen size unchanged from 2004 U/S CT chest – normal

6. CASE 4 2011 Bone Marrow Aspirate/Biopsy – Normal progenitors for all cell lines with no evidence of malignancy – Compatible with peripheral destruction/sequestration

7. CASE 4 2011 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

8. CASE 4 2011-13 Blood counts recovered though platelets remained lower than previous

9. CASE 4 DATEHBWBCPLTSBone Marrow 20051303.0115------------- 20061293.2132------------- 20071222.4113------------- 2008/2851.798Normal progenitor cells 2008/061193.0121-------------- 20091163.0108-------------- 20101323.0119-------------- 2011961.981Normal progenitor cells 20121252.972-------------- 20131292.955--------------

10. CASE 4 2012 Required a laparoscopic cholecystectomy and intra-operatively liver noted to be “coarse/nodular”

11. CASE 4 DATEASTALTALKBILIPLTSALBINR 200525177519115------------- 20082114281098-12148------ 20102316408119481.1 20121522331272491.1 No ETOH – significant previous history x 20 yrs HCV RNA/HBV DNA (-) secondary liver disease workup (-)

12. CASE 4 Fibroscan done…. 32.8 kpa! U/S – No varices – +Ascites – Liver 18.7 c.m/nodular contour – Spleen 18.9 cm – Normal portal/hepatic veins

13. 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

14. 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