Thảo luận ca bệnh VAAC III v EN

Case Discussion: Parts III - V Part III – History Tuyet returns to the clinic one month after starting ARV After two weeks she increased the dose of Nevirapine to 200mg twice a day She has been to the clinic every week for follow-up appointments  She has been tolerating the medication well She missed one dose of ARV because her son was in the hospital over night for a gastrointestinal infection and she had to stay with him  Part III – History Other than the one missed dose, she has taken her medicine regularly  She notes that the last week she has mild itching and rash on her arms and abdomen She has mild nausea, but no vomiting, no diarrhea, no abdominal pain, no fever Last week she had two glasses of beer when she went to her friend’s wedding  Her husband agreed to have an HIV test: the result was positive and he will go to the clinic next week to be checked  Part III – Physical Examination          T 37.3 BP 120/80 HR 84 RR 14 HEENT: normal, no icterus, no thrush No oral ulcers Neck: few tender lymph nodes on both sides, less than cm each Heart: normal Lungs: clear Abdomen: mild tenderness right upper quadrant Liver and spleen normal size No masses Extremities: no edema Skin: mild erythematous rash with 1-2 mm macules and papules on the arms, chest, abdomen No jaundice Neurologic exam: normal What are the possible diagnoses now?   The rash and itching could be due to allergy to medication She has been on Nevirapine for one month, which commonly causes allergic rashes You should also ask the patient about any other medications that she is taking and if she has received medications from any other sources outside of the HIV clinic Cotrimoxazole can also cause allergy The patient has right upper quadrant tenderness and mild nausea These could be signs of hepatitis One common side effect of Nevirapine is hepatitis The patient has had beer recently and with her history of chronic hepatitis B, this could increase the risk of hepatotoxicity from ARV What further evaluation you want to do?  Following the MOH guidelines, patients on Nevirapine should have ALT checked after one month of treatment and then every months In addition, patients on ARV should have ALT checked more frequently if there are any signs or symptoms of hepatitis  You should check ALT now  If available, also check CBC  After only one month on treatment, repeat CD4 testing is not necessary Part IV – History  Results of laboratory testing:  CBC: Hgb 12, Hct 35, platelet 150, WBC 4,800 lympho 25% ALT: 192  How would you treat the patient?    The most important thing is to counsel the patient not to drink any beer In combination with the ARV and chronic hepatitis B, even small amounts of beer will be toxic to the liver Stop any other medications that can cause hepatotoxicity The MOH guidelines recommend stopping Nevirapine if the ALT is more than times the upper limit of normal (ALT > 200) If the ALT is less than 200 and the patient has no or mild symptoms, then you can continue the ARV and follow the patient closely How would you treat the patient?  Remember that the 3TC is also treating the hepatitis B Do not stop the 3TC unless the patient becomes very sick If 3TC is stopped abruptly, the patient may have a flare up of the hepatitis B  You can treat the rash and itching with an antihistamine medication Would you change the ARV treatment?  It is not necessary to change or stop the ARV treatment at this time What counseling would you for the patient?  Stop all beer  Continue the ARV  Come back to the clinic or call if there is any worsening of the symptoms, such as fever, vomiting, jaundice, abdominal pain, worsening rash, development of oral ulcers (Stevens-Johnson Syndrome) Part V – History  Chi Tuyet comes back in two weeks She continued that ARV at the same dose and has not missed any pills in the last weeks  She took an oral antihistamine for 10 days She has not had any alcohol since the last visit The rash is better and almost completely resolved Part V – History  She is eating well and gained kg since the past visit No nausea, vomiting, abdominal pain or fever You decide to repeat the ALT and the result is 98  You counsel the patient to avoid any beer and to continue the ARV at the same dose She will come back to the clinic in weeks What is the follow-up plan?  Following the MOH protocol, during month the patient should follow-up every weeks  Due to the hepatitis and rash, you should have the patient come back in week  ... could be due to allergy to medication She has been on Nevirapine for one month, which commonly causes allergic rashes You should also ask the patient about any other medications that she is taking... medications that she is taking and if she has received medications from any other sources outside of the HIV clinic Cotrimoxazole can also cause allergy The patient has right upper quadrant tenderness... chronic hepatitis B, even small amounts of beer will be toxic to the liver Stop any other medications that can cause hepatotoxicity The MOH guidelines recommend stopping Nevirapine if the ALT is more