1. Case Study Cloete van Vuuren ID Physician

2. 50 year old male Abscess over L parotid gland Cryptoccal meningitis 2010 PTB 2010 – completed 6/12 of Rx Stopped TDF/FTC/Efv 1 year ago

3. Pus aspirated – ZN pos, GeneXpert Rif Resistant

4. 4

5. Sputum culture – Rif, INH resistant – Aminoglycoside and Moxifloxacin sensitive Initiated on Amikacin Moxifloxacin Teridizone Ethionamide PZA

7. ART 50 year old male Weight 33 kg CD4 = 49 sCreat = 70 Hemoglobin = 6.4 Calculated Creat clearance = 48.9 Unable to walk

8. Which ART Regime do you initiate this patient on? 1.Tenofovir/Emtricabine/Efavirenz 2.Zidovudine/lamivudine/Efavirenz 3.Stavudine/Lamivudine/Efavirenz 4.2NRTI + Nevirapine 5.2 NRTI + Aluvia

10. Delirium

11. Delirium? 1.Chronically ill and debilitated 2.Alcohol withdrawal 3.Secondary infection 4.Medication 5.Other

12. Which one of the following drugs is the most likely cause of his delirium? 1.Efavirenz 2.Moxifloxacin 3.Teridizone 4.Pyrazinamide 5.Ethionamide

13. Desperately trying to sort out his delirium: Biochemically normal No other infection identified Switched to Nevirapine Stop all TB drugs Haloperidol

14. Which side effects should be routinely monitored during the injection phase? 1.Renal function 2.Hearing test 3.Thyroid function 4.Liver function 5.Fullblood count

15. Delirium DVT

16. Is DVT’s associated with Tuberculosis or TB Rx? 1.Yes 2.No

18. Month 3 on MDR TB Rx: Due to his delirium it is impossible to do a hearing test Creatinine – 150 Hemoglobin increased to 10 g/dl Sputum culture negative

19. His Creatinine rises to 230 – will you stop the Amikacin? 1.Yes 2.No

22. Month 6 Can sit out – walk short distances Gaining weight 31kg – 45 kg More orientated Monthly sputum TB cultures negative Efavirenz – no effect on delirium

24. “BILATERAL SYMETRICAL HGH FREQ SNHL SEVERE TO PROFOUND (HEARING AID NEEDED) BUT HE DOESN’T WANT A HEARING AID.”

25. Discharge Will come to work daily – only “non-strenous”work Will DOT at ward

27. Does not come regularly for medication Often smells of alcohol Family? Social worker involved

30. Virological failure ? 1.Switch to AZT/3TC/Aluvia 2.Request Genotype 3.Tenofovir/3TC/Aluvia 4.Other

31. Adherence intervention DOT ART in the morning with MDRTB treatment

33. K103N, M184V

35. Disappeared for a month

38. Why is this patient not taking his treatment? 1.Treatment illiteracy 2.Social circumstances 3.Poor support 4.Mood disorders 5.Alcohol abuse

39. HIV Dementia

40. Conclusion Social circumstances Alcohol Delirium DVT HIV Dementia TB/MDR TB vs HIV “Human Nature”

41. Case 2

42. 1.When did you initiate your first patient on ART? 1.<2004 2.2004- 2007 3.2008-20010 4.2010 – 2015 5.None

43. Depressi on PNPN MI Choleste rol In-stent thrombosis

44. Aug10Sep 11Feb 12Oct 13 Total Cholestero l (mmol/l) 5.74.5 11.1 Trig (mmol/l) 56 HbA1C11.5%

45. Aug 10 Sep 11Feb 12Oct 13Mar14Apr 15 Total Cholesterol (mmol/l ) 5.74.5 11.16.08.5 Trig (mmol/l) 561932 HbA1C11.5%6.7%7.3%

48. Aug10Sep11Feb12Oct 13Mar14Apr 15Oct 15 Total Cholesterol (mmol/l) 5.74.5 11.16.08.54.6 Trig (mmol/l) 5619321.2 HbA1C11.5%6.7%7.3%

49. Case 3

51. In your experience, what is the most common reason for failing 2 nd line ART? 1.Not taking treatment 2.Not absorbing 3.Side effects 4.Mood disorders 5.Substance abuse

52. M41L D67N V75IM M184V L210W T215Y A98G V106I Y188L

53. Is she taking her treatment? 1.Yes 2.No

54. M41L D67N V75IM M184V L210W T215Y A98G V106I Y188L RHZE

55. What will you do? 1.Continue as is 2.Tdf/FTC/Raltegravir 3.Tdf/FTC/Raltegravir/Darunavir/r 4.Other

57. Conclusion Take nothing for granted (Double check everything and everybody)