1. CASE 2 49 yo man HIV+ 1995 Bipolar 2 disorder highlighted by major depression with a few serious suicide attempts and necessitating multiple hospital admissions Smoker 2ppd x 35 yrs Lives in a supervised setting

2. CASE 2 Tenofovir/FTC/RTV/Darunavir x 4yrs Quetiapine/Venlafaxine Remains adherent with both HIV and psychiatric meds CD4 currently 380/28% and stable over 4 yrs HIV viral load<40

3. CASE 2 Over last year unexplained weight loss of 23kg as documented in the chart…has become more precipitous over the last few months (5kg) No associated constitutional symptoms More fatigue/frequent napping noted Appetite poor

4. CASE 2 No cough/soboe/hemoptysis/chest pain No upper or lower GI symptoms No pain/discomfort No polyuria/polydypsia No obvious worsening of psychiatric condition No admitted illicit drug use WHAT WOULD YOU DO?

5. CASE 2 Bloodwork CBC/lytes/creatinine/glucose/hba1c/calcium/ liver enzymes/albumin/urinalysis/TSH/testostero ne all normal Radiology CXR/Ultrasound abdo/Chest CT normal

6. CASE 2 Temperature Chart normal WHAT DO YOU THINK? ANY OTHER INVESTIGATIONS TO ADD?

7. CASE 2 OGD/Colonoscopy Negative for lesions/abnormalities Urinary Drug Screen Positive for Cannabinoids++

8. CASE 2 Psychiatric opinion re: occult worsening depression Psychiatrist felt that excessive hidden marijuana use on a daily basis (>10gm/day) coupled with associated increasing paranoia/depression likely contributed to appetite/weight loss…marijuana confiscated and psychiatric meds readjusted

9. CASE 2 Fatigue improved Less frequent napping Appetite improving as now more awake for meals weight up 2 kg over last month