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HIV CASE PRESENTATIONSAnita Rachlis MD M.Ed FRCPCDavid Fletcher MD FRCPC

CASE 1

• 59 yo man • HIV+ since 1994• Asymptomatic

• CD4 150

CASE 1

DATE REGIMEN CD4 VL1996 AZT/3TC/IDV 150 -----------

--1997- 2004

AZT/3TC/RTV/SQV 310 700-500

Antiretroviral History

CASE 1

BASELINE GENOTYPE JUL/03

CASE 1Apr/2004• TDF/ABC/RTV/LPV/EFV/Rosuvastatin

Feb/2012• CD4 310 → 670•VL <40 c/ml

CASE 1Feb/2012…seen for usual F/U• Six month history of bilateral rib, leg

and foot pain along with muscle weakness and fatigue

• Exam unremarkable except for very slight proximal muscle weakness

WHAT WOULD YOU DO ?

CASE 1Feb/2012…• CK normal at 43• Rosuvastatin held

CASE 1Mar/2012…No improvement of pain off Rosuvastatin

CASE 1Mar/2012…further investigations:

• CBC normal• Creatinine 135• U/A… + GLU, 2+ protein• AST 19 ALT 18 ALP 353 CK 43• Random urine protein 3.325 g/l

CASE 1Mar/2012DATE Creatini

neU/A Alb/Cr

ratio2004 98 GLU (-)

Protein (-)--------

2006 99 --------------- <22009 107 GLU (-)

Protein (trace)

6.8

2010 104 ------------------

15.1

2012 135 GLU (+) Protein (3+)

29

CASE 1Mar/2012

DATE ALP2004 1062006 862007 952009 1282012 329

CASE 1Mar/2012…further investigations:–Calcium 2.19 PO4 0.58–Albumin 43–K+ 3.4 mmole/l, Bicarbonate 20

mmol/l– iPTH 10.7 pmol/l (<6.8 pmol/l=N)–Vitamin D (25HYDR)…42 nmol/l–ANA (-) RF (-)–Fractional excretion PO4..74%

CASE 1Mar/2012…further investigations:–U/S liver…normal/biliary system

normal

–HepA IgG/HepB SAB (+)–HepC AB (-) HCV RNA (-)

–ALP isoenzymes – bone significantly increased

CASE 1Mar/2012…further investigations• Xray ribs, knees, ankles & feet…normal

• Dexa Scan… Hip t -2.6, L spine t -3.1

• Bone Scan…↑uptake Lt 6th rib, Rt 3rd and 5th rib compatible with fractures

CASE 1Provisional diagnosis •Osteomalacia 2o hypophosphatemia due to Fanconis syndrome• Tenofovir discontinued and antiretroviral regimen switched to ABC/RTV/DRV/ETR/RGV• Supplemented with potassium phosphate and vitamin D /calcium

CASE 1Apr/2012…1 month later• Bone pain and muscle weakness have improved dramatically

• PO4 0.88 mmole/l Bicarbonate 24 mmole/l K+ 4.2 mmole//l

• Awaiting other f/u bloods