N.G. Registration No.1441

Background

• Female whose current age is 19 years• Registered at 13 years (17/2/2004), while in

S1 accompanied by the mother but had never been disclosed to.

• She is 3rd born child in the family• The rest of her siblings are health • Presented with severe wasting, HZ fresh scar

on chest at T.7., oral hairy leucoplakia, moderate anaemia and watery diarrhoea

• Stool investigation confirmed presence of Cyclospora oocysts

QUESTION:• What is the problem with this patient?

ART history

• She had been started on ART from another clinic (Case Western Reserve University clinic)

• Scanty records indicated that she started with

Stocrin, Varidex, Zerit from May 2000), failed before switching to TRIOMUNE 30 in August 2003

QUESTIONS:

1. Were these the right regimen choices?2. Any danger of drug interactions?3. What could have led to treatment failure?4. Would you continue with Triomune in this

patient?

Treatment decision

• Clinical discussion considered this as treatment failure

• Adequately counselled and disclosure process initiated

• Switched to AZT, 3TC,Lopinavir/Ritonavir one week after registration

Follow up • 4 months after switching to second line she

developed tetany of the limbs, severe anaemia and diarrhoea became more diffuse

QUESTIONS:• What is the problem?• How do you manage this patient?

Response

Investigation results:

• Serum amylase = 644 iu/L (27-131) • Serum lipase = 375 iu/L (10-220)• Serum albumin =24 g/L (31-54)• Total protein = 61 g/L (60-80)• Viral Load = 1,085 copies/mL, • CBC – Neutrophilia = (6700) • Haemoglobin = 11.4 g/dL

• K =2.3 mmol/L (NR=3-5) • Na = 142 mmol/L (NR=135-

145) • Serum calcium = 7.9mg/dL

(NR 9.2 -11.0), • Urine calcium = 2.05 mg/24

hours (NR 100 - 320).

A team of senior Paediatricians suspected hypocalcaemia and chronic pancreatitis probably kaletra-induced

• Rehyhdrated as in-patient with iv fluids• Given:

calcium supplementsCalcitonin to increase absorption of calciummagnesium sulphate Cimetidine tabsIV Gentamicin Haematenics

• Stopped all antiretroviral drugs suspecting• 2 weeks after all ARVs were stopped she

still had profuse diarrhoea and vomiting (re-admitted)

1 month later:• Serum calcium = 8.9 mg/dL (NR 8.1 -10.4),

Serum amylase 46 iu/L (up to 95), • Serum lipase = 78 iu/L (NR up to 190),• Abdominal u/s scan = normal

• Still had severe abdominal pain and occasional diarrhoea and vomiting

• Given:• IV Tagamet• Gaviscon liquid with iv pethidine • Generally improved

QUESTION:• What is the choice of ART to re-challenge this

patient?

• Later re-challenged with TDF,AZT,EFV

After 6 months:• Again switched to TDF,AZT,ABC after a

discussion between senior Paediatricians who thought that after failing on NVP then EFV was unlikely to be beneficial

• Later (Feb 2005), there was a discussion between PIDC and JCRC clinicians on how to manage this patient

• Consensus was that ABC will select for TDF resistance and hence NOT the best in combination

QUESTION:• What then would you switch to?

• ABC was stopped and switched to Nelfinavir

QUESTION:Was this the appropriate choice of drug to

substitute ABC?

2 weeks later:• Reviewed with fever, pedal oedema and oral

thrush and generally very weak and unable to open the mouth(BS negative for malaria)

• Gradually improved but with intermittent episodes of fever, watery diarrhea and abdominal pain

A month later:• She presented for the first time WITHOUT

complains (on 3/5/2010)

2 months later:

• WHO withdrew Nelfinavir from circulation due to toxicity

QUESTION:What would be your next step?•

Current regimen

In June 2005: • She was switched to AZT, TDF, Aluvia up to

date• Though poor adherence has bee reported she

is fairly stable and needs follow up

Laboratory results Date CD4 % CD4 count Viral Load

15/8/2003 4.8 133

04/2/2004 3.7 44 134,256

23/6/2004 8.3 141

31/8/2004 9.8 117

14/2/2005 12.6 177 < 400

23/8/2005 15.9 262

08/2/2006 24 306

25/8/2006 26 342

22/2/2007 27 468

22/8/2007 26 307

20/2/2008 23 233 < 400

27/8/2008 25 299

24/2/2009 22 240

18/8/2009 29 200 < 40

WAYFORWARD??

LESSONS LEARNT

• There is need for rational drug use (ART)• Team work is important in the ART

management of HIV• Never give up with treatment of children

CONCLUSIONS

• Antiretroviral therapy in children and adolescents in still a major challenge particularly in resource-limited settings

THANK YOU FOR YOUR PARTICIPATION