1. Case 10 63 year-old white UK male Living in non-urban Eastern England Married Grown-up children 1

2. Case 10: March 2006 Referred by GP to ED Seen by medical team and admitted with: –Recurrent chest problems –Cough –SOB 2

3. Case 10: PMH Seen by GP in Oct 2003 for itchy skin problems and diarrhoea Investigations: FBC –lymphopenia (1.3) –anaemia (12.9) –low total WBC (3.7) –platelets 115 –Total protein increased with globulins of 42 (diffuse hypergammaglobulinaemia) Referred to Dermatology OPD 3

4. Case 10: PMH Seen in Dermatology OPD Diagnosed with seborrhoeic dermatitis Treated with ketoconazole 2% cream In view of GI symptoms and haematological abnormalities Dermatology suggested urgent GI referral Referred to Gastroenterology OPD 4

5. Case 10: PMH (cont.) Seen in Gastroenterology OPD over 2004/05 Numerous investigations Low folate and B12 Treated with gluten-free diet but all tests for coeliacs disease negative Diarrhoea and weight loss continue Upper endoscopy NAD Colonoscopy December 2005 NAD 5

6. Case 10: March 2006 Investigations: CXR fine widespread pulmonary infiltrates ? Vasculitis ? Lymphangitis carcinomatosis Patient anxious, deteriorating, family worried Worsening SOB Further investigations: CXR – showed deterioration from the admission X-ray with diffuse interstitial shadowing both lung fields ? Pulmonary Embolism Angiogram done – no abnormality/evidence of PE seen 6

7. Case 10: April 2006 Radiologist doing angiogram queried appearance of CXR ? typical of PCP GUM asked to see ‘just in case’ Patient seen on ward – moribund Transferred to ITU immediately 7

8. Case 10: ITU April 2006 HIV test positive - CD4 = 40 PCP, influenza, CMV pneumonia and gastroenteritis, herpes simplex virus proctitis, candidiasis and C.difficile Extremely unwell for some weeks Nearly died Eventually recovered and discharged Doing well on antiretroviral therapy (ART) 8

9. Case 10: summary 2003Seen by GP for itchy skin problems and diarrhoea, found to have lymphopenia 2003Seen in Dermatology OPD for seborrhoeic dermatitis 2004-2005Seen in Gastroenterology OPD with recurrent diarrhoea and weight loss March 2006Admitted with recurrent chest infections, SOB April 2006PCP, CMV, HSV, oral candidiasis HIV diagnosed: CD4 40 9

10. Q: At which of his healthcare interactions could HIV testing have been performed? 1.When his GP detected lymphopenia? 2.When he was seen in Dermatology for seborrhoeic dermatitis? 3.When he was seen in Gastroenterology OPD for recurrent diarrhoea and weight loss? 4.When he was admitted with recurrent chest problems? 5.When he was investigated following abnormal CXR? 6.Should he have been referred to GUM to see a trained counsellor before HIV testing? 10

11. Who can test? 11 Who can test?

12. Who to test? 12

13. Who to test? 13

14. At least 4 missed opportunities! If current guidelines used, HIV diagnosed 2.5 years earlier 2003Seen by GP for itchy skin problems and diarrhoea, found to have lymphopenia 2003Seen in Dermatology OPD for seborrhoeic dermatitis 2004-2005Seen in Gastroenterology OPD with recurrent diarrhoea and weight loss March 2006Admitted with recurrent chest infections, SOB April 2006PCP, CMV, HSV, oral candidiasis HIV diagnosed (CD4 40) 14

15. Learning Points This patient had numerous investigations and a long ITU stay, causing him and his family much distress and costing the NHS thousands of pounds Because of his nadir CD4 of 40 he has an increased risk of potential problems despite control of his HIV now He did not disclose any risk factors when his initial medical history was taken Because of this the otherwise excellent medical teams looking after him did not think of HIV even when the diagnosis seems obvious with hindsight A perceived lack of risk should not deter you from offering a test when clinically indicated 15

16. Key messages Antiretroviral therapy (ART) has transformed treatment of HIV infection The benefits of early diagnosis of HIV are well recognised - not offering HIV testing represents a missed opportunity UK guidelines recommend routine offer of an HIV test for patients with lymphopenia HIV screening should become a routine test performed whenever there is a clinical indicator such as chronic diarrhoea or weight loss Some patients may not disclose that they have put themselves at risk of HIV infection in the past 16

17. 17 Also contains UK National Guidelines for HIV Testing 2008 from BASHH/BHIVA/BIS Available from: enquiries@medfash.bma.org.uk or 020 7383 6345