Andrea Sigrist
Clinical Case Scenario Presentation
KNH 411
November 20, 2012
Case 35: HIV
1. How is HIV transmitted? After reading Mr. Long’s history and physical, what risk factors would you say he has had for contracting HIV?
HIV is transmitted from one infected person to another by blood, semen, vaginal secretions, and breast milk. It can be transmitted by sexual contact, both intercourse and oral sex, direct blood contact, including sharing needles, blood transfusions, and accidents in health care settings, and from mother to child during breast feeding. Mr. Long used to work as a nurse in a dialysis center, so he could have contracted it at work from dealing with an infected patient. He also admitted to having multiple sexual partners of the opposite sex, so he could have also contracted the disease from a partner. He also admits to using recreational drugs, though he does not specific what drugs or how he is taking them, but he can contract HIV by sharing needles with an infected person.
AIDS.org (2012). AIDS Information, Education, Action, Awareness | How is HIV Transmitted? AIDS Information, Education, Action, Awareness | HIV, AIDS Facts. Retrieved from http://www.aids.org/topics/aids-faqs/how-is-hiv-transmitted/
2. Mr. Long says he found out he was HIV positive four years ago. Why is he only symptomatic now?
After being infected with HIV, many patients experience flu-like symptoms that go away within a few weeks and their body behaves as usual. The progression of the disease varies from person to person, so patients may not notice symptoms again for more than ten years. The amount of time before a person notices symptoms depends on how active the virus is in that particular person and how fast the virus multiples, infects, and then kills the cells of the immune system. The virus has taken four years to kill enough cells to show symptoms.
WebMD (2007). HIV & AIDS Symptoms: Weight Loss, Lack of Energy, Fever, and More. WebMD - Better information. Better health. Retrieved from http://www.webmd.com/hiv-aids/guide/hiv-symptoms
3. The history and physical indicate that he is seropositive. What does that mean? The Western Blot and ELISA confirmed that he was seropositive. Describe these tests.
Seropositive means a patient has positive results or high levels of antibodies on the results of a serological examination. The Western Blot test is done to detect specific proteins in a sample. The test is done by sorting proteins by length on a gel and then seeing if any of the proteins will stick to a specific antibody. If a person is HIV positive, they will have antibodies against one of the envelope proteins and one of the core proteins, or against one of the enzymes. ELISA (enzyme-linked immunosorbent assay) is done to look at how much of an antibody is in a sample or how much protein is bound by an antibody. A 96-well plate is used to test the blood and see if a specific antigen is linked to an enzyme. If a person is HIV positive, the serum with change to a different color.
Boskey, Ph. D., E. (2011, September 6). HIV Testing - How Does a Western Blot HIV Test Work? Sexually Transmitted Diseases - STDs. Retrieved from http://std.about.com/od/HIVTesting/f/How-Does-A-Western-Blot-Hiv-Test-Work.htm
Medline Plus (2010, October 30). ELISA: MedlinePlus Medical Encyclopedia. National Library of Medicine - National Institutes of Health. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/003332.htm
4. What is thrush, and why might Mr. Long have this condition?
Thrush is a yeast infection of the mucous membrane lining the mouth and tongue. Mr. Long might have this condition because the HIV makes his immune system very week. His CD4 cell levels, which help fight off diseases, are very low, so he is not able to fight off the fungus as easily.
Carter, M. (2011, April 11). HIV & AIDS Information: Candida (thrush). HIV & AIDS Information: Home. Retrieved from http://www.aidsmap.com/Candida-thrush/page/1044820/
5. What are common nutritional complications of HIV and AIDS? After reading Mr. Long’s history and physical, can you identify any of these complications in him?
One of the major nutritional complications associated with HIV and AIDS is malnutrition. Because of a weakened immune system, infections, and side-effects of treatment, patients may experience loss of appetite, diarrhea, nausea, vomiting, and mouth sores, which cause a patient to stop eating or lose any energy and nutrients they take in. Their nutrient metabolism changes, positive and negative acute-phase proteins are produced which affect macro- and micronutrient absorption, and some micronutrient and mineral levels decrease. Mr. Long has mouth and throat sores, and describes his appetite as “not normal”, both of which are affecting his ability to eat and causing him to lose weight.
Health24 (n.d.). Nutrition and Aids, HIV/Aids - Health24. Health24 - South Africa's premier health and wellness site, provides world-class information and interactive tools for a healthy lifestyle. Retrieved from http://www.health24.com/medical/Condition_centres/777-792-814-1769.asp
Pg. 750
6. After this admission Mr. Long was diagnosed with AIDS, Category C2. What information can you see from his medical record that confirms this diagnosis?
Mr. Long has thrush, has lost less than 10% of his body weight, and his T-cells, helper t-cells, and t-suppressor cells are all well below normal range. These symptoms along with herpes zoster, minor mucocutaneous manifestations, recurrent bacterial upper respiratory tract infections, and fungal infections, are criteria for HIV Clinical Stage 2.
Pg. 744
7. Evaluate the patient’s anthropometric information.
a. Calculate %UBW and BMI.
% UBW = 151lbs/ 165lbs x 100 = 91.5%
BMI = 68.64kg/ (1.8542m)(1.8542m) = 19.96
b. Compare the TSF to population standards. What does this comparison mean? Is this a viable comparison?
Mr. Long’s TSF: 7mm
Normal TSF measurement: 15.1 to 85
Mr. Long is below average and his measurement is so low that there is likely total body wasting. Because his measurement is so low, I think other tests should be used in addition. A skin fold test would help compare him to the rest of the population.
Pg. 51
c. Using MAC and TSF, calculate upper arm muscle area. What can you infer from this calculation?
AMA for males in mm2= [MAC (cm) - (3.14 x TSF in cm)]2 - 10
4 x 3.14
[25.4 – (3.14 x .07)]2 – 10
4 x 3.14
= 634.042472– 10
12.56
= 40.48 mm2
Adequate muscle mass for a man is at least 54. Mr. Long is only at 40.48, which puts him in the marginal category. He is within 75%, so this measurement does not cause a lot of concern.
Pg. 50
d. Mr. Long’s body fat percentage is 12.5%. What does this mean? Compare to standards.
Healthy body fat percentages for men ages 20-39 are 8% to 19%. Mr. Long is in the middle of this range, so he is considered to have a healthy amount of body fat.
Fit Day (2011). What is a Normal Body Fat Percentage? / Fitness / Weight Loss. FitDay - Free Weight Loss and Diet Journal. Retrieved from http://www.fitday.com/fitness-articles/fitness/weight-loss/what-is-a-normal-body-fat-percentage.html
e. Summarize Mr. Long’s nutritional risk (if any) from your assessment of anthropometric information.
Mr. Long’s nutritional status is not good and he is at risk for being considered unhealthy. He BMI is lower than a man of his age should be and he is losing muscle mass.
8. Evaluate Mr. Long’s dietary information. What tools could you use to evaluate his dietary intake? Does he seem to be consuming adequate amounts of food? Can you identify anything from his history that indicates he is having difficulty eating? Explain.
I would use a diet tracker, such as Fitday.com to assess his diet because it will calculate the macronutrients he is consuming and intake what he is consuming too much and too little of. I enter Mr. Long’s diet into the site and it calculated that he consumed about 1,979 calories, 64.8 grams of fat, 228.4 grams of carbohydrate, 71.3 grams of protein a day. His diet was below the RDA for a man of his age and stature. Mr. Long is lacking adequate amounts of vitamin A, B6, B12, C, D, E, calcium, copper, iron, magnesium, manganese, niacin, phosphorus, potassium, riboflavin, selenium, sodium, thiamin, and zinc. A food journal and site like Fitday.com could help a dietitian monitor his diet and make sure he is consuming adequate nutrition.
FitDay. (2012). FitDay - Free Weight Loss and Diet Journal. Retrieved from http://www.fitday.com/fitness/FoodLog.html?_a_Date=1322611200.&_v_View_FoodL ogSummaryTabs-Focus=Nutri
9. Mr. Long states that he consumes alcohol several times a week. Are there any contraindications for alcohol consumption for him?
The main contradiction of Mr. Long’s alcohol use is its interaction with the medications he was just prescribed. Alcohol can slow down the effectiveness of antiretroviral therapies, which will affect the progression of the HIV infection.
Cooper, C. L., & Cameron, D. W. (2005). Effect of Alcohol Use and Highly Active Antiretroviral Therapy on Plasma Levels of Hepatitis C Virus (HCV) in Patients Coinfected with HIV and HCV. Oxford Journals | Medicine | Clinical Infectious Diseases. Retrieved from http://cid.oxfordjournals.org/content/41/Supplement_1/S105.full
10. Using this patient’s laboratory values, identify those labs used to monitor his HIV. What do these specifically measure, and how would you interpret them for him?
The labs used to monitor his HIV are CD4 (helper t-cells) and CD8 (suppressor t-cells). These cells help the body fight off diseases and the level indicates how strong a person’s immune system is. I would explain to Mr. Long that these levels along with a Viral load test can be used as an indication of the progression of the disease and evaluate if the treatment is effective. Mr. Long’s CD4 and CD8 count are very low and the viral load is very high. The Centers for Disease Control and Prevention consider a person with HIV to have progressed to AIDS when they have a CD4 count below 200 cells/mm3, and Mr. Longs count is 157 cells/mm3 indicating he now has AIDS.
AIDS (2012). AIDS Information, Education, Action, Awareness | CD4 (T-CELL) TESTS. AIDS Information, Education, Action, Awareness | HIV, AIDS Facts. Retrieved from http://www.aids.org/topics/aids-factsheets/aids-background-information/what-is-aids/hiv-testing/cd4-t-cell-tests/
11. What laboratory values can be used to evaluate nutritional status? Are there any for Mr. Long that identify nutritional risk?
The laboratory values used to evaluate his nutritional status are albumin, prealbumin, and BUN tests. Albumin and prealbumin levels shows how much protein is in the blood, which can indicate if there are problems with the kidney or liver due to the HIV. The BUN tests show hydration levels and how well the kidneys are functioning. His albumin and BUN levels are normal values, but his prealbumin level is slightly lower than normal.
12. Calculate Mr. Long’s optimal energy and protein intake. How does this compare to his diet history?
Energy needs:
10x wt (kg) + 6.25 x ht (cm) – 5 x age (yrs) + 5
10 x 68.64 + 6.25 x 185.42 – 5 x 32 + 5
686.4 + 1158.875 – 165 = 1,680.275
EER: 662- (9.53 x 32) + 1.7(15.91 x 68.64 + 539.6 x 1.8542) = 3,914.4
Protein needs:
3,914.4 x 0.15= 587.16/4 = 146.79g
Mr. Long is not consuming enough nutrient-dense foods and is consuming a lot of empty calories. He is not eating adequate calories, protein, carbohydrates or fat.
13. What other information would you want to obtain from Mr. Long in order to fully evaluate his nutritional status?
I would also like to know why he is not able to work right now, what his daily activity level is, and find out if he is sleeping through the night to get an adequate amount of sleep. I would like Mr. Long to track his diet for an entire week and would like to know what kind of recreational drugs he is doing.
14. Mr. Long started on three medications that he will be discharged on.
a. Identify these medications and the purpose of each.
1. AZT (ziduvudine) – helps to decrease the amount of HIV in the body so the immune system can work better. It also lowers the changes of getting HIV complications and improves quality of life.
2. Crixivan (indinavir) - helps to decrease the amount of HIV in the body so the immune system can work better. It also lowers the changes of getting HIV complications and improves quality of life.
3. Epivir (lamivudine) - helps to decrease the amount of HIV in the body so the immune system can work better. It also lowers the changes of getting HIV complications and improves quality of life.
b. Are there any specific drug-nutrient interactions to be concerned about? Explain.
1. AZT (ziduvudine) – herbal products such as ginseng and milk thistle because they may interact.
2. Crixivan (indinavir) – It should not be taken with meals high in fat, calories, or protein because this may decrease its effects. He should also avoid grapefruit, herbal supplements, and St. John’s wort.
3. Epivir (lamivudine) – Alcohol may increase liver problem risks or lead to pancreatitis. Herbal products also interact with this medication.
c. Is there specific information you would want Mr. Long to know about taking these medications?
Mr. Long should be careful about taking herbal products because of the interactions with ziduvudine and should avoid alcohol because it may lessen the effectiveness of the medications and be too hard on the kidneys. Indinavir should be taken with a full glass of water and on an empty stomach. He should also make sure he is consuming at least 6 glasses of water a day to reduce the risk of developing kidney stones. Epivir must be taken exactly as prescribed because changing the dose or skipping a dose may increase the amount of the virus, make the infection more difficult to treat, or worsen the side effects.