CASE PRESENTATION ON ZIDOVUDINE INDUCED ANAEMIA
Jan 15, 2016
CASE PRESENTATION
ON
ZIDOVUDINE INDUCED ANAEMIA
CASE PROFILE
A male patient of age 36 years who was HIV positive presents to HIV Department OP with the complaints of breathlessness and giddiness on 22-10-2011.By examining the patient physician advised to admit in the Ward
Breathlessness on exertion since 20 days
Giddiness and fever since 20 days
Headache
Fatigability
Body pains
CHIEF COMPLAINTS
Pallor + + RS :NAD CVS: Tachycardia P/A:Soft,tender in the epigastric
and left hypochondriac region Ht:159.5cms Wt:68 kgs Temp:98F BP:120/70 mm of Hg
DATE OF ADMISSION:22-10-2011DATE OF DISCHARGE:2-11-2011
On Examination
FAMILY HISTORY:
Wife - HIV positive3 childrens:13 years/F-Positive 12years/M-Positive 3 years/M-Negative
SOCIAL HISTORY:
Patient is a driverHe is smoker and alcoholicHe quits alcohol 3 months back
History
PAST MEDICAL AND MEDICATION HISTORY
Patient was diagnosed as HIV positve on 21-09-2007.
ART started on 11-08-2011 with AZT/3TC/NVP
ART changed on 17-10-2011 with DT4/3TC/NVP
Newly diagnosed as hypertensive 5 days back and prescribed withRamipril 1.25mg once daily
ART-Anti retro viral therapy
AZT-Zidovudine
3TC-Lamivudine
NVP-Nevirapine
DT4-Stavudine
CD4-320 cells on 4-09-2007
CD4-318 cells on 10-03-2008
CD4-354 cells on 19-9-2008
CD4-331 cells on 27-04-2009
CD4-329 cells on 04-08-2009
CD4-340 cells on 26-03-2010
CD4-281 cells on 17-02-2011
CD4-213 cells on 04-08-2011
CD4 Count of Patient
Sp Estimated. compound Normal value Observed value
22-1-2011 23-1-2011 24-1-2011Hb 11-16.5g/dl 5.1g/dl 5.18g/dl 6.5g/dl
TC 3500-10000/cum 5100/cum 5100/cum 2700/cum
DC lymphoctes 15-30% 46.2% 46.2% 42.4%
Neutrophils 40-70% 49.2% 49.2% 52.8%
Mid cells 2-10% 4.6% 4.6% 4.8%
PCV 35-50% 12.7% 12.7% 17.6%
Platelets 1-4lac cells/cum 1,79000 179000 130000
MCH 25.4 - 34.6 pg/cell
28.5 30.1pg/dl 28.4pg/dl
MCHC 31-37 % 38.8% 39.9% 36.99%
RBC 3.80-5.80m/cu 1.2m/cu 1.7m/cu 2.3m/ cu
Total Lymphocytes
15-30% 17% 13% 1.1%
Total Neutrophills 40-80% 13% 1.4% 1.4%
Total Midcells <01% 1% 0.2% 2%
RDWA 11.5-14.0 56.9% 61.6% 64.2%
MPV 7-9 7.7fL 7.6 7.4
PDW <12.0 12.4 11.8 11.8
MCV 7-9 7.3 -
BLOOD
Tests Specimen Est. compound Normal values Observed values
R F
T
RBS 110-180mg/dl 134.4mg/dl
Blood Urea 10-50mg/dl 24.7mg/dl
Sr.creatinine 0.6-1.1mg/dl 0.8mg/dl
Na 135-148mmol/l
139.9mmol/l
K 3.5-5.3mmol/l 4.32mmol/l
Cl 98-107mmol/l 108mmol/l
LDH 150-330U/l 343
L F
T
Bilurubin Total 0.5-1.1mg/dl 0.3mg/dl
Bilurubin Direct Upto 3mg/dl 0.1mg/dl
SGOT 6-38IU/L 25.7IU/L
SGPT 6-38IU/L 43.5IU/L
ALP 36-142mml/ml 76.1mml/ml
Sr.Albumin 3.5-5.0g/dl 4.5g/dl
Total Proteins 6.8-8.3g/dl 7.5g/dl
BLOOD
MP: Negative
Urine albumin-TraceSugar-NillMicro, Pus cells < 2Epithelial cells few <5
Urine Analysis
Vit-B12-549.9pg/ml
Normocytic, normochromic RBCTC-2500/cumSputum AFB-NegativePlatelets are adequate
PERIPHERAL SMEAR
24-10-2011
NORMAL COUNT:
Viral load : <46c/ml <200c/ml
ELISA:
0.089-Non reactive>0.7 –Reactive
DIAGNOSIS:
HTN-Newly diagnosedZidovudine induced anaemia
Blood transfusion done on 22-10-2011 and 2-10-2011
NORMAL COUNT
ELISA
DIAGNOSIS
DIAGNOSIS
ZIDOVuDInE INDUCE
ANAEMIA
The anaemia caused by zidovudine is multifactorial and dose dependent.
It inhibits the proliferation of blood cell progenitor cells in a time and dose dependant fashion.
Zidovidine exhibits cytotoxicity to the myeloid and erythroid precursor in the bone marrow. There by it inhibit the production of RBC.
So haemoglobin monitoring is done particularly in those patients who are taking zidovudine.
Reference: Zidovidine induced anaemia in HIV/AIDS Indian J Med Res 132,october 2010 pp 359-361
.
ZIDOVUDINE INDUCED ANAEMIA
CLINICAL GOALS: Prolongation of life and improvement in quality of life.
VIROLOGICAL GOALS: Greatest possible reduction in the viral load for as long as possible
THERAPEUTIC GOALS: Rational sequencing of drugs in a fashion that achieves clinical, virological and immunological goals while maintaining treatment options, limiting drug toxicity and facilitating adherence
Effective therapy is usually accompanied by a CD4+ cell count increase of 100-200/µL or more within 2 to 4 months.
Reference: Standard treatment guidlines-A manual for medical therapeutics ,Third Edition by sangeetha sharma
GOALS OF “ART” ARE
DRUG DOSE FREQ R.O.A
22 23 24 25
T.Paracetamol 650mg TID PO -
T. Thiamine 75mg Stat PO -
T. Ramipril 1.25mg OD PO - - -
T. Trimethoprim+Sulfamethaxazole
800mg+160mg OD PO - - -
T.Iron and Folic acid
200mg+0.5mg OD PO - - - -
DT3/3TC/NVP 40mg+300mg+200mg
BD PO - - - -
PRESENT MEDICATION
1. Blood pressure was normalized
2. Haemoglobin levels are increased by blood transfusion.
3. Signs and symptoms are relieved
4. Viral load and CD4 count is maintained
THERAPEUTIC OUTCOME
Vitamin B complex OD for 15 days
Co-trimoxazole single strength tablet (80/400) OD for 15 days
Review after 2 weeks
Repeat Hb%Check blood pressure .
DISCHARGE MEDICATIONS
NRTIS are associated with lactic acidosis, lipoatropy and peripheral neuropathy which leads to non-adherence to the long term therapy.
DRUG RELATED PROBLEMS
1) Clinical assessment should be done on each visit of the patient.
2) Routine monitoring of the CD4 count of the patient should be done for every 6 months.
3) Monitoring of complete blood count should be done.
4) Monitoring of short term and long term toxicity of stavudine should be done.
5) Monitoring of the viral load should be done.
MONITORING PARAMETERS
1. Counselling should be done regarding the understanding of ART medications
2. Counsel the patient for better medication adherence.
3. Inform the patient about the adverse effects of ART drugs.
4. Advice the patient to regularly visit the physician.
Life style modifications:
Avoid smoking
PATIENT COUNSELLING
DIETARY RECOMMENDATIONS
Advice the patient to take more green leafy vegetables.
To take enriched bread and cereals and a good source of ascorbic acid at each meal like citrus foods, orange juices, fresh lime improves the absorption of iron.
Advice the patient to take dry foods.
THANKING YOU