Thảo luận ca bệnh VAAC III v EN

 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..  The patient has

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 1 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 do you want

 Following the MOH guidelines, patients on

Nevirapine should have ALT checked after one

month of treatment and then every 6 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?

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.

hepatotoxicity.

Nevirapine if the ALT is more than 5 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

anti-histamine 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 do

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 2 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 1 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 2 weeks

What is the follow-up plan?

 Following the MOH protocol, during month 2 the

patient should follow-up every 2 weeks

 Due to the hepatitis and rash, you should have the

patient come back in 1 week