A Pediatric HIV Patient With Fever and Headache (original) (raw)
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A 9 Year Old Female Ethiopian Patient with Stage IV Retroviral Infection and Right Side Hemiparesis
Journal of Antivirals & Antiretrovirals, 2017
A 9-year-old, 17 kg, female patient was admitted to pediatric ward of a large, teaching referral hospital in Addis Ababa, Ethiopia because of high grade fever (HGF), severe headache & abnormal body movement (ABM) of 1 month duration. The child was taking unspecified Highly Active Antiretroviral Therapy (HAART) regimen from another government hospital ART clinic and unspecified per os (PO) medicines and herbs ordered from private clinics and traditional herbalists, respectively. She was put on Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) fixed dose combination therapy since 8 months back and has been taking phenytoin 50mg PO BID for the last one and half year. The patient has no known drug allergy (NKDA) or allergic diseases. Brain Computed Tomography (CT) scan was done on 27/02/2017 and revealed the presence of Pyogenic Brain Abscess (PBA) with subfalcine Herniation. Abdominal ultrasound was done on 08/03/2017 and showed Hepatomegaly. Head Magnetic Resonant Imaging (MRI) was done on 09/03/2017 and showed Left Frontoparietal Multiloculated Ring Enhancing Lesion with calcification and extensive vasogenic edema & mass effect more likely a Tuberculosis Brain Abscess (TBA). Chest X-ray (CXR) was done on 09/03/2017 with anterioposterior & left lateral position and revealed Left Upper Lobe Opacity more likely Tuberculosis (TB). Patient's hemoglobin (Hgb), mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH) all were below normal on two consecutive measurements indicating that patient was suffering from moderate microcytic anemia. The Erythrocyte sedimentation rate (ESR) was also elevated as indication of non specific chronic inflammatory conditions most probably due to TB. Urinalysis was done on date 06/03/2017 and showed slight elevation in Red Blood Cells (RBCs) and White Blood Cells (WBCs) count and serum electrolyte assessment showed potassium was slightly below normal and chloride was increased and serum pH was slightly high causing metabolic alkalosis. Furthermore, alkaline phosphatase (ALP) was slightly elevated indicating involvement of cranial bone and focal hepatic lesions. Based on the clinical, laboratory and imaging evidences, the final working diagnosis was Stage IV RVI on HAART plus Right Sided Hemiparesis Secondary to TBA and PBA plus Focal Seizure. The gradual worsening of ABM of right lower and upper extremities could be due to lack of appropriate titration of the dose of phenytoin. The Initial dose of phenytoin has to be initiated with 5 mg/kg/day orally in 2 or 3 equally divided doses, with subsequent dosage individualized to a maximum of 300 mg PO daily. The maintenance dose should be 4 to 8 mg/kg and for children over 6 years old and adolescents may require the minimum adult dose (300 mg/day). The major drug therapy problems identified in this case was the prescription of rifampin with dexamethasone or prednisolone. Rifampin has been known to decrease the level or effect of dexamethasone-prednisolone by affecting hepatic/intestinal CYP3A4 enzyme metabolism. Hence, avoiding the use or use of alternative drug was recommended. Based on subjective evidences from the patient, now the patient is feeling better. Imaging modalities and laboratory tests are expected to be repeated and further progress report will be reported in future correspondence as short communication or to the editorial note Her ABM was exacerbated in the last one month and her mother took her to different private clinics and traditional healers where many unrecognized orally administered medications were given. The child was diagnosed as 'Stage IV RVI+Right Side Hemiparesis secondary to Pyogenic Brain Abscess+Focal Seizure' at ARTH. Otherwise the patient had no history of cough at night, sweating or contact with active TB patient, no loss of consciousness with or without ABM, no trauma or fall down accident or urinary retention. The mother claimed that her child has been adhered to the ART medications. The recent (1 month back) CD4 count was 317/mm3 with unknown baseline CD4 count. Her past medical history (PMH) showed no other documented illness except being a known RVI for 8 years and the ABM of one & half year durations. Her social history showed, she was exclusively on breast feeding (EBF) up to one year and was fully vaccinated according to the Ethiopian Expanded Program for Immunization (EPI) schedule. The child is currently a first grade Volume 9(2): 043-051 (2017)-43
A 9-year-old, 17 kg, female patient was admitted to pediatric ward of a large, teaching referral hospital in Addis Ababa, Ethiopia because of high grade fever (HGF), severe headache & abnormal body movement (ABM) of 1 month duration. The child was taking unspecified Highly Active Antiretroviral Therapy (HAART) regimen from another government hospital ART clinic and unspecified per os (PO) medicines and herbs ordered from private clinics and traditional herbalists, respectively. She was put on Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) fixed dose combination therapy since 8 months back and has been taking phenytoin 50mg PO BID for the last one and half year. The patient has no known drug allergy (NKDA) or allergic diseases. Brain Computed Tomography (CT) scan was done on 27/02/2017 and revealed the presence of Pyogenic Brain Abscess (PBA) with subfalcine Herniation. Abdominal ultrasound was done on 08/03/2017 and showed Hepatomegaly. Head Magnetic Resonant Imaging (MRI) was done on 09/03/2017 and showed Left Frontoparietal Multiloculated Ring Enhancing Lesion with calcification and extensive vasogenic edema & mass effect more likely a Tuberculosis Brain Abscess (TBA). Chest X-ray (CXR) was done on 09/03/2017 with anterioposterior & left lateral position and revealed Left Upper Lobe Opacity more likely Tuberculosis (TB). Patient's hemoglobin (Hgb), mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH) all were below normal on two consecutive measurements indicating that patient was suffering from moderate microcytic anemia. The Erythrocyte sedimentation rate (ESR) was also elevated as indication of non specific chronic inflammatory conditions most probably due to TB. Urinalysis was done on date 06/03/2017 and showed slight elevation in Red Blood Cells (RBCs) and White Blood Cells (WBCs) count and serum electrolyte assessment showed potassium was slightly below normal and chloride was increased and serum pH was slightly high causing metabolic alkalosis. Furthermore, alkaline phosphatase (ALP) was slightly elevated indicating involvement of cranial bone and focal hepatic lesions. Based on the clinical, laboratory and imaging evidences, the final working diagnosis was Stage IV RVI on HAART plus Right Sided Hemiparesis Secondary to TBA and PBA plus Focal Seizure. The gradual worsening of ABM of right lower and upper extremities could be due to lack of appropriate titration of the dose of phenytoin. The Initial dose of phenytoin has to be initiated with 5 mg/kg/day orally in 2 or 3 equally divided doses, with subsequent dosage individualized to a maximum of 300 mg PO daily. The maintenance dose should be 4 to 8 mg/kg and for children over 6 years old and adolescents may require the minimum adult dose (300 mg/day). The major drug therapy problems identified in this case was the prescription of rifampin with dexamethasone or prednisolone. Rifampin has been known to decrease the level or effect of dexamethasone-prednisolone by affecting hepatic/intestinal CYP3A4 enzyme metabolism. Hence, avoiding the use or use of alternative drug was recommended. Based on subjective evidences from the patient, now the patient is feeling better. Imaging modalities and laboratory tests are expected to be repeated and further progress report will be reported in future correspondence as short communication or to the editorial note Her ABM was exacerbated in the last one month and her mother took her to different private clinics and traditional healers where many unrecognized orally administered medications were given. The child was diagnosed as 'Stage IV RVI+Right Side Hemiparesis secondary to Pyogenic Brain Abscess+Focal Seizure' at ARTH. Otherwise the patient had no history of cough at night, sweating or contact with active TB patient, no loss of consciousness with or without ABM, no trauma or fall down accident or urinary retention. The mother claimed that her child has been adhered to the ART medications. The recent (1 month back) CD4 count was 317/mm3 with unknown baseline CD4 count. Her past medical history (PMH) showed no other documented illness except being a known RVI for 8 years and the ABM of one & half year durations. Her social history showed, she was exclusively on breast feeding (EBF) up to one year and was fully vaccinated according to the Ethiopian Expanded Program for Immunization (EPI) schedule. The child is currently a first grade A 9-year-old female patient was admitted to pediatric ward of a large, central referral hospital in Addis Ababa, Ethiopia-Tikur Anbessa Specialized Hospital (TASH, where clinical pharmacists affiliated with this hospital works) because of HGF, severe headache & ABM of 1 month duration. The child was a known HIV infected patient for the last 8 years and has been on HAART for the last 7 years. She was referred from Asella Referral Teaching Hospital (ARTH, a referral & teaching hospital 170 km away from Addis Ababa towards SouthEast Ethiopia) after presented with ABM of right lower extremity (RLE) since one and half year back & ABM of right upper extremity (RUE) since 8 months back for which Phenytoin 50 mg PO twice a day was initiated. J Antivir Antiretrovir, an open access journal