Long Case Webinars - Medflix

Question 1

Kidney disease (+ transplant)

Answer 1

Cause may be unknown, diabetes commonly causes CKD. ?biopsy prior
Risk factors like low socioeconomic bg, other pmhx.
EGFR or creatinine, urea
Mx- dialysis, duration / timing and dry weight
- haemodialysis (fistulas, complications)
- peritoneal dialysis (peritonitis)
Complications-
-CVD, anaemia, bone health, thrombosis, stroke
Prognosis- adherence, pt understanding
Eligibility for transplant

Question 2

Asthma / COPD

Answer 2

Mmrc grading
Exercise tolerance
Diagnosis made by ?
Occupational and environmental exposures : smoking, fam hx, asbestos, silicosis, birds
Control: reliever use, preventer
Ix : FEV1/FVC ratio
Mx: IgE / IL-5 antibodies

Question 3

HIV
-mode of acquisition.
-seroconversion.
-complications.
. constitutional symptoms
. opportunistic infection
A. TB
B. Cyptococcal meningitis
C. Hepatitis
. respiratory
. gastro
. neuro
. renal
. ocular
. derm
. mouth
. cardiac
. haem
. aids definining illness
. IRIS
-investigations
-management
. medication
A. integrase inhibitor
B. reverse transcriptase inhibitor
C. protease inhibitor
. vaccination
. pregnancy
. PrEP
-long term complications
-social

Answer 3

Mode of acquisition.

Seroconversion (3-6/52 post)

Complications:
-constitutional symptoms
-opportunistic infection
A. TB (start tx for HIV 2-8/52 of dx, depending on if CD4 < or > 50, TB meningitis delay tx of HIV until tx of TB).
B. Cryptococcal meningitis (tx HIV 4-6/52 after ampho induction, fluconazole consolidation and chronic maintenance until HIV suppressed, control ICH with LP and lumbar drains…tx HIV sooner if CD4 <50 or mild infection and later if severe (up to 10 weeks). Concern for IRIS after ARVs (fever, haemolytic anaemia, CN palsy, seizures, MRI lesions tx NSAIDs + pred).
C. Hepatitis: lamivudine, emtricitabine
-respiratory: PJP, lymphoid interstitial pneumonitis, TB, bacterial pneumonia, fungal pneumonia
-gastro: cryptosporidiosis, mycobacteria, HSV or CMV ulcer, biliary, drug SE
-neuro: meningitis, focal neurology or seizure with space occupying lesions, toxoplasma or NHL, dementia, multifocal leukoencephalopathy, peripheral neuropathy, CMV radiculopathy or myopathy, neurosyphilis
-renal: HIV nephropathy, sepsis, drug SE
-ocular: CMV retinitis
-derm: drug, HZV or HSV, fungal, kaposi sarcoma
-mouth: ulcer, gingivitis, periodontal disease, candida.
-cardiac: myocarditis, percarditis
-haem: pancytopenia.
-AIDS definining illness: PJP, toxoplasma encephalitis, CMV retinitis (ARV, IV ganciclovir improve 10-14/7), disseminated mycobacterium avium complex / TB (MAI), oesophageal candidiasis, chronic cryptosporidiosis, kaposi sarcoma (HHV8)
-IRIS (6/52 post ARV): OIs, sarcoidosis, graves, folliculitis. High VL, low CD4 or high pathogen burden.

INVESTIGATIONS:
Diagnosis: NAT (11/7), Ab + p24 (16/7), Ab (21/7).
CD4 count (infection risk)
Viral load (dx control)

MANAGEMENT:
Medication:
A. 1x Integrase inhibitor (dolutegravir)
B. 2x reverse transcriptase inhibitor
- NRTI:
. lamivudine/ abacavir (allergy, HLAB5701)
. lamivudine/ zidovudine (anemia, lipodystrophy)
. tenofovir (renal, bone)
. emtricitabine
- NNRTI: efavirenz (CNS toxicity, dreams/suicidality).
C. Protease inhibitors = boosters (ritonavir- CYP3A4 inhibitor, cobicistat, inhibits tubular secretion.

Vaccination: avoid live.
Prophylaxis:
CD4 < 200 = PJP (co-trim, dapsone, primaquin + clinda, pentamidine).
CD4 <100 = Toxoplasma (TMPSMX)

Pregnancy:
-preferred: tenofovir, abacavir, lamivudine, emtricitabine + raltegravir
-alternative: zidovudine + dolutegravir

PrEP: Tenofovir/emtricitabine for 90 days.
-HIV test 3/12
-CrCl 6/12
-risk reduction, adherance, condoms
-STI ax

Long term complications:
Cardiovascular risk:
-lipid tx with pravastatin
Malignancy
CKD
Depression / dementia
Adherence / insight: >95% adherence correlates to cure.

SOCIAL:
-isolation
-relationships
-finances
-substance use
-mood

Question 4

Cardiac long case

Answer 4

-cardiac risk factors
- lifestyle changes
- adherence to medications
- missed appointments with specialist / contact with regular GP
- dry weight, current weight, frusemide titration education
-social hx: functional ability, stairs, pets, friends and family, finances, medication administration
- psychological impact, impact on QoL
- prognosis and palliative care if appropriate, recurrent hospitalisation indicates poor prognosis

Question 5

Heart transplant

Answer 5

Indication for transplant such as young, not responding to current management.

Exclusion criteria like use of substances, non adherent.

No innervation to heart so ?ongoing chest pain.
Endocardial biopsy.

Psychological impact
Acute and chronic rejection

Question 6

Lung transplant

Answer 6

Poor prognosis, 6 year life expectancy due to increased exposure to pathogens from environment.
CF patients, improved medications like ivacaftor now.
Dual organ transplant.
Transplant medication SE’s.
Poorer prognosis with increased severe infections.

Question 7

PJP prophylaxis

Answer 7

Pred >20mg/d for >4/52

ALL induction - maintenance

Allo-HSCT - 6/12 post

Alemtuzumab, rituximab, anti-thymocyte - 6/12 post

Solid organ transplant >6/12 (?lifelong for lung/intestinal tplant).