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Dr Andy WilliamsBarts and The London NHS Trust
17TH ANNUAL CONFERENCE OF THE
BRITISH HIV ASSOCIATION (BHIVA)
6-8 April 2011, Bournemouth International Centre
The Faces of Janus
The Returning Traveller
Dr Andy Williams
Barts and the London NHS Trust
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Meet Amina:
� 32 ♀� Sudanese
� In UK since 2000
� HIV 2001
� START 2005 (CBV/SAQ/RIT)
� Klebsiella empyema Nov 2009 – Rx Imipenem
� VATS pleuradhesis
Meet Amina:
� 32 ♀� Sudanese
� In UK since 2000
� HIV 2001
� START 2005 (CBV/SAQ/RIT)
� Klebsiella empyema Nov 2009 – Rx Imipenem
� VATS pleuradhesis
CD4 211 (16%)
Viral Load 87,975OUTPATIENT FOLLOW UP FOR EARLY PART OF 2010
UNTIL……
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A&E Presentation April 2010A&E Presentation April 2010
� Pyrexial - septic shock – ITU for BP support
� Pancytopaenic
� Mildly deranged LFTs & LDH
� Renal function normal
� CD4 186 (12%)
� CMV –ve, HHV8 VL –ve X2
Hb 6
Plts 80
WCC 3.6
Neut 1.6, Eo 0.5, Lym 1.0
AST 51
Bili 36
Alb 23
LDH 550
CRP 205
Travel History - In Sudan July 2009
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EUREKA MOMENTEUREKA MOMENT
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Common Infections in South Sudan
� Kala azar
� Onchocerciasis
� Babesiosis
� Trypanosomiasis
� Falciparum Malaria
Common Infections in South Sudan
� Kala azar
� Onchocerciasis
� Babesiosis
� Trypanosomiasis
� Falciparum Malaria
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Blood Film 1st May 2010
What does the blood film show?
� Babesiosis
� Plasmodium ovale infection
� Trypanosomiasis
� Dengue Fever
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Microscopic features of Microscopic features of P. P. OvaleOvale
� Similar to P. Vivax
� Schuffner’s dots on surface of parasitisedRBC are larger and darker than in P. Vivax
� About 20% of parasitised cells are oval in shape
� Some of the oval cells have fimbriatededges – the comet cell
� Mature P. Ovale schizonts never have more than 12 nuclei
Plasmodium ovale
� Species of parasitic protozoa that causes tertian malaria in humans
� First described in a patient from East Africa in 1922
� Usually limited to West Africa – has been reported throughout Africa
� Also reported in The Philippines, Eastern Indonesia and Papua New Guinea
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Treatment and follow up
� Chloroquine base loading then 310mg od 3/7 then Primaquine 15mg od 2/52
� Prescribed Truvada/Darunavir/Ritonavir
� Poor attendance for appointments
� ?Adhering to ARVs
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July ‘09 Nov ‘09 April ‘10 Aug ‘10 Oct ‘10 April ‘11
Sudan SudanP. ovaleKlebsiella empyema
Symptoms Loss of appetiteFevers/sweatingWeight lossMarked swelling of face R>L
2009 2010 2011
What was happening in October 2010?
� Relapsing form of malaria
� Allergic reaction to ARVs
� Superior Vena Cava Obstruction
� Something else tropical
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On examination
• Marked periorbital swelling – both eyes and up into forehead (R>L)• Soft swelling, not hot or tender• No conjunctival injection• Bilateral Axillary LNs noted• Joints normal
Eosinophils 0.51Random cortisol normalMRA/MRV head and neck – normalLN Bx – Non specific
External help requestedExternal help requested
� Immunology review – Asymmetrical so allergy unlikely
� Referred to Tropical Medicine at UCH
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Hospital for Tropical Diseases Results
� Diagnosis: Schistosomiasis - likely past infection
Strongyloidiasis -ve
Toxocariasis -ve
Toxoplasmosis -ve
Cysticercosis -ve
Schistosomal ELISA Positive at level one
Hospital for Tropical Diseases Results
� Diagnosis: Schistosomiasis - likely past infection
� Suggested treatment – Two doses of praziquantel 20mg/kg with 6 hour gap between the doses.
Strongyloidiasis -ve
Toxocariasis -ve
Toxoplasmosis -ve
Cysticercosis -ve
Schistosomal ELISA Positive at level one
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SCHISTOSOMIASIS DOESN’T CAUSE FACIAL SYMPTOMS.....
Returned to HIV clinic
� Symptoms unchanged
� New lumps noticed on legs
� Ongoing lymphadenopathy
� Face swelling worse
� Punch biopsy taken of leg lesion
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High power view H&E
What infection does the histology show?
� Plasmodium ovale
� Gnathostomiasis
� HHV8 related disease
� Loaiasis
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What infection does the histology show?
� Plasmodium ovale
� Gnathostomiasis
� HHV8 related disease
� Loaiasis
Final Diagnoses and progressFinal Diagnoses and progress
1. Plasmodium ovale infection
2. Nodal and cutaneous Kaposi’s sarcoma
� HIV VL suppressed
� CD4>400
� Undergoing treatment with liposomal doxorubicin
� Lymph nodes and facial swelling↓
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Learning Points
� She would have benefited from earlier HAART
� Multidisciplinary input vital
� Important to examine head to toe
� All that glitters is not gold
AcknowledgementsAcknowledgements
� Drs Chloe Orkin & Guy Baily
Consultant HIV Physicians
Royal London Hospital
� Dr Tom Doherty
Hospital for Tropical Diseases
UCH London
