identifying hiv and viral hepatitis in the primary care setting patty w. wright, md march 2011

Identifying HIV and Viral Hepatitis in the

Primary Care Setting

Patty W. Wright, MD

March 2011

Objective

To familiarize participants with common presentations of acute HIV infection, AIDS, and acute and chronic viral hepatitis (including Hepatitis A, B, & C)

Case 1: H&P

A 50 year old asymptomatic male banker is diagnosed with hyperlipidemia on routine fasting cholesterol testing. He is currently on no prescription medications, herbals, or OTC meds. Prior to starting a statin he has baseline LFT testing which is significant for the following: ALT 165, AST 72, TBili 0.8.

Case 1: Questions

What additional history would you like to obtain?

What infections are on your differential?

What additional tests would you recommend?

Case 1: Additional History

The patient reports that he has been monogamous with his wife x 25 years. He denies any current or prior history of IVDA. He does not drink alcohol. He denies a prior h/o jaundice. He reports that he was the passenger in an MVA at the age of 6 and required abdominal surgery. He does not know if he required a blood transfusion at that time.

Case 1: Differential

As patient is asymptomatic with elevated ALT, chronic hepatitis most likely

Hepatitis C and B are most likely causes of chronic viral hepatitis

Differential also includes non-infectious causes of chronic hepatitis

Case 1: Additional Studies & Diagnosis

Hepatitis A and B serologies: negative Hepatitis C antibody: positive Hepatitis C PCR: positive

Dx: Chronic HCV Infection

HCV Epidemiology

~ 4 million infected in the U.S. (prevalence ~ 1.8%) ~ 3 million in the U.S. with chronic infxn HCV-related end-stage liver disease is

leading indication for liver transplant in U.S.

About half of new cases occur in IVDA Many have no identifiable mode of

acquisition

Features of HCV InfectionFeatures of HCV Infection

• Incubation periodIncubation period Average 6-7 wksAverage 6-7 wksRange 2-26 wksRange 2-26 wks

• Acute illness (jaundice)Acute illness (jaundice) Mild (Mild (<< 20%) 20%)• Fulminant hepatitis RareRare• Chronic infectionChronic infection 60%-85%60%-85%• Chronic hepatitisChronic hepatitis 10%-70%10%-70%• CirrhosisCirrhosis 5%-20%5%-20%• Mortality from CLDMortality from CLD 1%-5%1%-5%

HCV: Natural HistoryAcuteAcute HCVHCV

ChronicChronic HCVHCV ResolutionResolution

CirrhosisCirrhosis

HCCHCC

StableStable InfectionInfection

20%20%80%80%

20%20% 80%80%

1-4%/year1-4%/year

Age, SexAlcohol

Co-infection

(HBV, HIV)~20

year

s

Recommendations for HCV Testing

Ever injected illegal drugs Received clotting factors made before 1987 Received blood/organs before July 1992 Ever on chronic hemodialysis Evidence of liver disease Following needle stick/mucosal exposures to

HCV-positive blood Children born to HCV-positive women

HCV Antibody 3rd generation ELISA: sensitivity > 99% Indicates prior infection, but does not

distinguish cleared infection from chronic infection

HCV antibody is not protective Re-infection with HCV may occur after

prior clearance

HCV RNA PCR

Defines active infection (viral replication)

Quantitative PCR useful to monitor response & durability of treatment

After HCV Diagnosis

Assess for biochemical evidence of chronic liver disease

Assess for severity of disease and possible treatment, according to current practice guidelines

Vaccinate against hepatitis A and B Counsel to reduce further harm to liver

Limit or abstain from alcohol

Case 2: H&P

A 21 year old male college student presents to the ED with a two week history of fatigue, rash, fever, H/A, & sore throat. He has no known tick or mosquito bites. He traveled to Detroit 4 wks ago.

Exam is significant for a temperature of 99.9, a faint macular-papular rash on the trunk, shotty cervical LAD, and mild erythema of the O/P without exudate.

Labs: WBC 4.4, N 54% L 27% M 19%; CMP WNL

Case 2: Questions

What syndrome does this patient have?



Case 2: Syndrome and Possible Etiologies

This patient has a “mono-like illness”

Potential causes include acute EBV CMV Toxoplasmosis HIV


EBV serologies: negative CMV serologies: c/w past infection RMSF serologies: negative Ehrlichia PCR: negative HIV ELISA: negative HIV-1 RNA > 100,000 copies/ml

Dx: Acute HIV Infection

Acute HIV: Symptoms

1 mil

100,000

10,000

1,000

100

10

+

_HIV

RN

AH

IV-1

An

tibo

die

s

Exposure

P24 +

0 20 30 40 50

Symptoms

Days

HIV RNA

Ab

Typical Course of Primary HIV

Importance of Diagnosing Acute HIV

Up to 50% of all HIV transmission due to primary / early infection when viral loads are very high and patients often asymptomatic

Antiretroviral therapy started during acute / early infection may help preserve HIV-specific immune function and provide better long-term control of the infection

Oregon Department of Human Services HIV/STD/TB Program

Case 3: H&P

A 47 year old female teacher with no significant past medical history presents to the clinic with a note from the Red Cross stating that she tested positive for Hepatitis B when she went to donate blood. Her lab report reveals a positive hepatitis B surface antigen.

Case 3: Additional Studies & Question

Hepatitis B surface antigen: positive Hepatitis B total core antibody: positive Hepatitis B core IgM: negative Hepatitis B surface antibody: negative

What is the status of the patient HBV infection?

Case 3: Diagnosis

Dx: Chronic Hepatitis B Infection

Features of HBV InfectionFeatures of HBV Infection

• Incubation period Average 60-90 days Range 45-180 days

• Clinical illness <5 yrs, <10%(jaundice) >5 yrs, 30%-50%

• Acute case-fatality rate 0.5%-1%

• Chronic infection <5 yrs, 30%-90% >5 yrs, 2%-10%

• Premature mortality fromchronic liver disease 15%-25%

HBV Epidemiology

140,000-320,000 acute infections in U.S. each year

> 1 million in U.S. with chronic infection

Leading cause of chronic liver disease & hepatocellular carcinoma (HCC) worldwide

www.pathology.med.ohio-state.edu

Acute HBV Infxn w/ Recovery

Weeks after Exposure

Symptoms

HBeAg anti-HBe

Total anti-HBc

IgM anti-HBc

anti-HBsHBsAg

0 4 8 12 16 20 24 28 32 36 52 100

Tit

er

Chronic HBV Infection

IgM anti-HBc

Total anti-HBcHBsAg

Acute(6 months)

HBeAg

Chronic(Years)

anti-HBe

0 4 8 12 16 20 24 28 32 36 52

Weeks after Exposure

Tit

er

After HBV Diagnosis

Assess for biochemical evidence of chronic liver disease

Assess for severity of disease and possible treatment, according to current practice guidelines (some po options available)

Vaccinate against hepatitis A Counsel to reduce further harm to liver

Limit or abstain from alcohol

www.exchangesupplies.org

Case 4: H&P

A 47 year old Amish farmer presents with low grade fever, shortness of breath, and nonproductive cough which has worsened over the past month. He was treated with azithromycin without improvement. He presents to the ED with worsening symptoms.

Exam: T 99.8, RR 30, P 106, RA O2 sat 91%chest - bilateral dry crackles

Case 4: H&P

Labs: WBC 3.2,

75% segs,

20% monos,

LFT’s WNL,

LDH 767

Case 4: Questions




Case 4: Additional History, DDx, & Studies

No travel or sick contacts. Has exposure to dogs, horses, and cows. He reports adherence to prior abx therapy.

Differential includes causes of atypical pneumonia, such as Mycoplasma, Legionella, and viral infections.

Chest CT shows diffuse bilateral infiltrates. Blood and sputum cx are negative.

Nasal swab viral antigen testing negative.

Case 4: Additional History, Studies, & Diagnosis

Bronchoscopy with special stains positive for Pneumocystis jirovecii ("yee row vet zee")

HIV antibody positive with CD4 count 105 Upon additional questioning, the patient

admits to traveling out-of-town on a monthly basis to visit prostitutes.

Dx: Chronic HIV Infection / AIDS

After AIDS Diagnosis

Important to consider need for prophylaxis of opportunistic infections as well as treatment of underlying HIV

AIDS patients at increased risk of certain cancers and cardiovascular disease Follow appropriate cancer screening guidelines

and management of cardiovascular risk factors Pap smears Q6 months for women with AIDS

HIV primary care guidelines: Clinical Infectious Diseases 2009;49:651–681

www.ehivtest.com

Case 5: H&P

A 25 year old male waiter presents with abdominal pain, N/V, anorexia, malaise, and low grade fever x 5 days.

On exam, he is noted to have right upper quadrant tenderness and scleral icterus.

Labs: ALT 1450, AST 1080, Tbili 10.8, Alk phos 157

Case 5: Questions




Case 5: Additional History

Patient reports that he drinks occasional wine with dinner. He denies street drugs. He is sexually active with men. He has not been previously vaccinated against viral hepatitis.

www.merck.com/mmpe

Evaluation of Acute Hepatitis

www.merck.com/mmpe

Case 5: Additional Studies and Diagnosis

Hepatitis B surface antigen: negative Hepatitis C antibody: negative Hepatitis A IgM: positive

Dx: Acute Hepatitis A Infection

Features of HAV InfectionFeatures of HAV Infection•Jaundice by <6 yrs <10% age group 6-14 yrs 40%-50% >14 yrs 70%-80%

•Rare complications Fulminant hepatitis Cholestatic hepatitis

Relapsing hepatitis

•Incubation period Average 30 days Range 15-50 days

•Chronic sequelae None*

* HAV antibodies provide lifelong immunity

HAV Epidemiology

Most disease occurs in the context of community-wide outbreaks

Infection transmitted from person to person in households and extended family settings Facilitated by asymptomatic infection among

children Some groups at increased risk, such as men who

have sex with men No risk factor identified for 40%-50% of cases

Hepatitis A Incidence:Effect of Vaccination Campaign

rate per 100,000 0-4 5-9 10-19>=20

DC

NYC

rate per 100,000 0-4 5-9 10-19>=20

DC

NYC

> = 20

10 - 19

5 - 9

0 - 4

Rate per 100,000

2002 incidence

1987-97 average incidence

After HAV Diagnosis

Assess for evidence of fulminant liver disease No specific therapy; Supportive care only Notify health department

Source investigation Post-exposure prophylaxis for contacts

Case 6: H&P

A 44 year old male with HIV and HTN is admitted with chest pain. He is treated for unstable angina and released on metoprolol, simvastatin, and aspirin, in addition to his prior antiretroviral regimen of AZT, 3TC, and lopinavir/ritonavir (“Kaletra”). He returns to the clinic a month later c/o fatigue, myalgias, and weakness.

Case 6: Questions

What is the most likely cause of the patients symptoms?

What additional tests would you order?


The patients symptoms are concerning for myositis related to his statin

Additional studies reveal a CPK of 5,800

Dx: Drug-Drug Interaction

Antiretroviral Drug-Drug Interactions Many antiretrovirals affect the cytochrome

P450 system This is particularly true of protease inhibitors

Protease inhibitors may increase levels of certain statins by 3,000 % Avoid simvastatin, lovastatin May use pravastatin and low dose atorvastatin

Use caution with benzodiazapems Severe respiratory depression may occur

HIV : Conclusions

Consider evaluation for acute HIV with HIV viral load testing in all adult patients with “mono-like” syndromes

Consider routine HIV antibody testing for all adult and adolescent patients (ages 13-64 yrs) as per CDC recommendations

Check for drug-drug interactions before prescribing any new medication for a patient on antiretroviral therapy

Viral Hepatitis: Conclusions

Evaluation of acute hepatitis should include HAV IgM antibody, HBV surface antigen, and HCV antibody testing

HBV surface antibody positivity indicates HBV immunity/cleared infection

HCV antibody positivity indicates prior exposure to HCV; HCV viral load testing is needed to determine infection activity

HAV and HBV are vaccine preventable!

Questions?

identifying hiv and viral hepatitis in the primary care setting patty w. wright, md march 2011

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