Title: Complications Toxicity Case 7: Mitchell
1Complications ToxicityCase 7 Mitchell
2Complications ToxicityCase 7 Mitchell
- 38 year old fashion designer
- First diagnosed positive 1990
- CD4 count 380
- HBcAb positive, sAg negative
3Complications ToxicityCase 7 Mitchell
Antiviral History
- 1996 - 1997
- AZT/3TC/SAQ
- 1998
- D4T/DDI/Efavirenz
- 1998
- DDI/HU/RIT/IND
- CD4 292
- CD4 242
- VL 220000
- Peripheral neuropathy/CNS toxicity
- CD4 298
- VL lt400
4Complications ToxicityCase 7 Mitchell
- Lost to follow-up Australia
- No HAART since 1998
- Jan 2002 acute hepatitis, fevers and night
sweats - CD4 2
- VL 450000
- Acute CMV hepatitis and MAI infection
- Rx iv Gancyclovir, Azithromycin, Ofloxacin and
Ethambutol
5Complications ToxicityCase 7 Mitchell
Back to the hospital June 2002
- On DDI (400mg)/Tenofovir/Abacavir
- i.v. Gancyclovir 5mg/kg/day
- Azithromycin, Ofloxacin, Ethambutol
- CD4 2
- VL lt400
- Started on Cotrimoxazole 960mg/day
- Gancyclovir stopped (CMV-PCR ve, No
retinitis or retinal scars)
6Complications ToxicityCase 7 Mitchell
- July 2002
- Intractable Oesophageal candidiasis
- No response to Itraconazole, fluconazole
- Admitted to the ward for i.v Amphotericin B
- Reduced CrCl within 48hours 58 l/min
- Switched to liposomal amphotericin
- 2 days later abdominal pain, nausea and
vomiting, increasing shortness of breath
7Complications ToxicityCase 7 Mitchell
Blood
- HB 13.3
- Plats 138
- WCC 12.3 (n11.1)
- Clotting (N)
- Blood cultures nil
- Mid stream urine (MSU) - nil
- Na 136
- K 3.1
- Urea 9.8
- Creatinine 110
- Amylase 983
- Bicarbonate 14
- Lactate 2.6
- Chloride 113
- Liver enzymes (N)
- CRP 110
8Complications ToxicityCase 7 Mitchell
- Chest X-Ray
- No abnormalities detected
- ABGs
- pH 7.18
- pO2 11.4
- pCO2 2.8
- Bicarb 12
9Complications ToxicityCase 7 Mitchell
10Complications ToxicityCase 7 Mitchell
- Acute Pancreatitis
- DDI/Tenofovir ?role of renal impairment
- Metabolic acidosis
- Anion gap (Na K) (HCO3 Cl)
- 10 (NR 10-20)
- Hyperchloraemic metabolic acidosis
11Complications ToxicityCase 7 Mitchell
- Causes of normal anion gap acidosis
- Gastrointestinal HCO3 loss
- pancreatic fistula ?
- Renal Tubular Acidosis (RTA)
- drug-induced ?
- Ingestion/Infusion Ammonium chloride/cationic
amino acids - Dilutional acidosis
12Complications ToxicityCase 7 Mitchell
- Type 1 RTA
- Low urine pH/low K
- Type 2 RTA
- Low/High urine pH/low K
- Type 3 RTA
- Low urine pH/High K
13Complications ToxicityCase 7 Mitchell
- Management
- ALL drugs except septrin stopped
- Supportive and fluids
- Bicarbonate supplements
- Over the next two weeks
- Amylase returned to normal
- RTA resolved bicarbonate eventually withdrawn
14Complications ToxicityCase 7 Mitchell
- BUT
- Progressive increase in ALT/AST/ALP
- Acute cholestatic hepatitis
15Complications ToxicityCase 7 Mitchell
Investigations
- U/S scan NAD
- ERCP normal intrahepatic ducts and CBD and
pancreatic ducts. Samples taken
- HBV DNA ve
- HDV IgM ve
- HAV total Ab ve
- HVC-RNA ve
- Blood CMV-PCR ve
- Blood Toxo-PCR ve
- MAI cultures taken
- Bile microscopy -ve
16Complications - Mr MM 38 years
- Liver biopsy moderate periportal and hepatic
inflammation with a predominant eosinophilic
infiltrate. No AAFBs or other organisms - Diagnosis Drug-induced hepatitis
- SEPTRIN INDUCED!
17Summary Complications - Mr MM 38 years
- DDI/Tenofovir pancreatitis
- Drug-induced Type 1 RTA - ?Amphotericin/TFV
- Septrin related hepatitis
- Rx for oesophageal candidiasis
- Anti-retroviral therapy