Download - Hiv tb final
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COINFECTIA HIV-COINFECTIA HIV-TB TB
0 PROBLEMA DE ACTUALITATE?0 PROBLEMA DE ACTUALITATE?
Dr. Cristina Nicolau, medic primar boli infectioase
Dr. Andreea Zabara Antal, medic rezident pneumologie
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DATE DE ISTORICDATE DE ISTORIC1959 - primul caz de infectie HIV( barbat din
Leopoldville- Congo-Belgian , in urma testarilor efectuate pe sangele congelat in 1998);
1966 - decesul unui navigator belgian confirmat 20 ani mai tarziu cu imunosupresie;
1981 - Dr Peter Piot (Belgia) apare ipoteza etiologiei virale corelata cu deficitul imun a unei noi boli;
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DATE DE ISTORICDATE DE ISTORIC1983- Franta – Dr Luc Montagnier descopera virusul
imunodeficientei umane;
1989 – primele cazuri de HIV pediatric in Romania–tinute sub tacere;
1990 - Romania raporteaza 1094 de SIDA la copii reprezentand jumatate din cazurile din Europa;
1990 - se introduce testarea obligatorie a donatorilor;
1991 - se stabileste in Romania metodologia de raportare HIV;
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DATE DE ISTORICDATE DE ISTORIC
1993 - CDC Atlanta modifica definitia SIDA pentru CD4<200 cel/mm3;
1997 - se infiinteaza Comisia Nationala de Lupta Anti Sida cu ramificatii in teritoriu prin Centrele Regionale de Monitorizare (CD4, VL);
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Clasificarea CDC AtlantaClasificarea CDC Atlanta
Seropozitiv HIV A1
Seropozitiv HIV A2
SIDA A3
Seropozitiv HIV B1
Seropozitiv HIV B2
SIDA B3
SIDA C1
SIDA C2
SIDA C3
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Semnificatia stadialializariiSemnificatia stadialializarii
• Limfocitele CD4 = capacitatea de aparare a organismului.
Semnificatia lor in cadrul bolii SIDA:
>500 = stadiul 1 (seropozitiv HIV sau Boala Sida ) ;
200-500= stadiul 2 (seropozitiv HIV sau Boala Sida ) ;
<200= stadiul 3 (boala).
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Categorii cliniceCategorii clinice
A. Asimptomatic
- Adenopatie generalizata persistenta (diametru >1cm, in cel putin 2 arii gangl, cel putin 3-6 luni fara a se putea demonstra o alta etiologie);
- Infectia primara (acuta) = 40-90% asimptomatica (frecvent = Sindrom mononucleozic la 2-4 sapt. de la momentul infectant; clinic = febra, astenie, scadere ponderala, mialgii, artralgii).
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Categorii cliniceCategorii cliniceB. -simptome constitutionale: febra 38.5 grade Celsius (peste 1 luna), scadere in greutate peste 10% din greutatea corporala, diaree trenanta cu durata peste 1 luna, - hepatita cronica Ag HBs+,- candidoza orofaringiana, vulvovaginala (persisistenta ,recidivanta sau rezistenta la tratament), -herpes zoster (cel putin 2 episoade pe an sau interesand mai mult decat un dermatomer),-carcinom cervical in situ.
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Categorii cliniceCategorii clinice
C. = SIDA
- Cancer cervical invaziv; - Leucoencefalopatia multifocala progresiva; - TBC pulmonar si extrapulmonar; - Toxoplasmoza cerebrala; - Limfom Burkitt, imunoblastic; - Infectie cu CMV-extrahepatica, splenica sau ganglionara; - Meningita cu Cryptococcus neoformans; - Pneumocistoza; - Sindrom de slabire; - Criptosporidioza
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Provocarea iniţierii tProvocarea iniţierii tratamentuluiratamentuluibariere posibilebariere posibile
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Facilitarea aderentei la Facilitarea aderentei la tratamenttratament
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Situatia la nivel national
12.886 persoane infectate HIV/SIDA în viaţă la 31 decembrie 2014 (20.146 total cumulativ, începând cu anul 1985).
10.261 persoane aflate în evidență activă la 31 decembrie 2014 primesc terapie specifică
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CENTRUL REGIONAL DE SUPRAVEGHERE SI MONITORIZARE HIV/SIDA IASI
Pacienti aflati in evidenta activa la 31decembrie 2014 1424 in tratament ARV =1308
M
FF46.7%
M53.3%
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REPARTIZAREA PE JUDETE
IASI
BC
BT
NT
SV
VS
SV 13.2%
VS 9.5%
IS 20.5
BC 24.9
BT 13.34%
NT 18.5%
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HIV/SIDA &TB3.Numar cazuri HIV/SIDA vechidiagnosticati/confirmati cu TBC
(solicitat de AIDS Reporting/UNAIDS-WHO);
Judet
IASI
NT SV BT BC VSTOTA
L
Nr. Pac.dg TBC. 2 5 1 4 5 4 21
4.. Numar cazuri HIV/SIDA noi diagnosticati/confirmati cu TBC (solicitat de AIDS Reporting/UNAIDS-WHO);
5.Numar pacienti diagnosticati/confirmati cu TBC/MDR/XMDR (solicitat de AIDS Reporting/UNAIDS-WHO);
6. Numarul pacientilor care au primit profilaxie TBC (solicitat de AIDS Reporting/UNAIDS-WHO);
Judet
IASI
NT SV BT BC VSTOTA
L
Nr. Pac.dg TBC. 1 4 0 0 1 2 8
Judet
IASI
NT SV BT BC VSTOTA
L
Nr. Pac.dg TBC. 0 3 1 0 0 0 4
Judet
IASI
NT SV BT BC VSTOTA
L
Nr. Profilax. TBC. 0 4 2 0 6 0 12
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Caz clinicCaz clinic
varsta 33 ani, sex feminin, mediul urbannivel de pregatire: studii superioaresot si copil de 4 ani aparent sanatosiactualmente: sarcina 23 saptamani in evolutieM.I. febra inalta (39,2˚C), tuse productiva
ineficienta, dispnee cu ortopnee, dificultate la deglutitie, fatigabilitate.
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Clinic si paraclinicClinic si paraclinic
Stare generala sever influentata, hipotensiune arteriala (85/45mmHg), tahicardie (125bpm), polipnee(42/min), SpO2=88%
Fenomene de insuficienta respiratorie acutaAnemie (Hb-10,7%) cu
leucopenie(G.A-2810/mm3,PMN-75,7%),VSH-70mm/1h
Radiografia toracica:aspect de bronhopneumonieTBC
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In serviciul T.IIn serviciul T.I. . Ventilata pe masca in mod non-invazivEchilibrata hemodinamic si respiratorUlterior transferata in serviciul de
pneumoftiziologie (T.I)-pt 72h, se mentine ventilatia non-invaziva, nefiind necesara intubarea, sputa pozitiva pt BK,se initiaza terapia antiTB cu HIN-300mg, Rifa 600mg, PZN 1750mg , ETB 1400mg
Test Elisa HIV (1+2 ) conform protocolului – intens pozitiv
Retransferata in serviciul nostru – compartiment HIV/Sida
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In serviciul HIV/SIDAIn serviciul HIV/SIDA
ancheta epidemiologica deceleaza faptul ca pacienta mai efectuase un test HIV cu ocazia primei sarcini (2009)
la comunicarea rezultatului pacienta era deja externata(nastere naturala , fara complicatii)
isi schimba adresa de domiciliu asigurata prin OPSNAJ (prin natura serviciului)
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La reluarea anamnezeiLa reluarea anamnezeiTest HIV negativ in 2004 la casatorie Test HIV negativ in 2007 la angajareTest HIV pozitiv in 2009 la nastere ( fara a fi putut fi
comunicat rezultatul??? )Sarcina nesupravegheata prin MF si nici prin
“serviciul de ginecologie”Scor Apgar 9, nastere naturala, alaptat la san 9 luni Evolutia ulterioara a copilului grevata de
numeroase infectii respiratorii intercurente
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In prezentIn prezent
Ancheta epidemiologica:• sotul seronegativ HIV• copilul de 4 ani seropozitiv HIV std B2, candidoza
oro-faringiana, hipotrofie staturo-ponderala, infectie cu CMV; CD4=565cel/mm3, VL=186.000copii/ml,Ag HBs – neg, Ac anti HCV – abs, serologie T.gondi – IgM-abs , IgG<4 ui/l, serologie CMV- IgM-abs IgG-296 ui/l.
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Statusul viro-imunologic al mameiStatusul viro-imunologic al mamei
CD4 – 6 cel/mm3VL – 189.000 copii/mlAg HBs – neg Ac anti HCV – absserologie T.gondi – IgM-abs , IgG<4 ui/lserologie CMV- IgM-abs , IgG-67 ui/lBoala Sida – std C3TBC pulmonar cu BK pozitiv Sarcina 23 saptamini in evolutiePancitopenie Candidoza oro-faringiana Profilaxia Pneumocistozei
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Tratament instituit-principiiTratament instituit-principiisa tina cont de asocierea cu TB si sarcina
usor de administrat remontarea rapida a imunitatii in vederea pregatirii
pentru cezariana sa pastreze optiuni ulterioare de tratament in
conditiile abordarii actuale ca o terapie de “salvare“
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Conform ghidului TARV…Conform ghidului TARV…
Cand incepem TARV?La toti pacientii infectati cu HIV, la momentul diagnosticarii.Cu ce incepem TARV?
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Conform ghidului TARVConform ghidului TARV
Monitorizare
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Conform Ghidului TARVConform Ghidului TARVCosturi tabel
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Conform ghidului TARVConform ghidului TARV
Coinfectia HIV-TB
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Si atunci am decis...Si atunci am decis...
Raltegravir +T20 +3TC
Biseptol tb2/zi de 3ori/sapt
cvadrupla terapia anti TBC
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Sarcina in evolutieSarcina in evolutie
monitorizata intr-un serviciu privat de OG fara a se efectua testul HIV - nerecomandat, neefectuat voit???
evolutia aparent normala a sarcinii dar cu un Triplu Test cu un rezultat incert (conform declaratiilor sotului)
naste prin operatie cezariana programata,n.n de sex M, Gn- 2500g , APGAR 9
profilaxia transmiterii M-F cu AZT+3TCVL- ARN HIV – ND la momentul nasterii si la o luna
de viata.
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Evolutia mameiEvolutia mamei Viata in patruViata in patru
mentine aceeasi schema de terapie ARV
actualmente stabila viro-imunologic
CD4- 358 cel/mm3 VL- nedectabila
dificila in conditiile in care mama aparent colaboreaza cu psihologul dar comportamentul in cuplu contrazice previziunile pozitive
mama refuza apropierea de primul copil , motivand necesitatea apropierii de cel de al doilea copil ( primul – la bunici de la diagnosticare )
armonia cuplului distrusa , erodata si probabil compromisa pe termen lung de pacienta
- “pasarea” poverii pe umerii sotului in conditiile acceptului facil al diagnosticului si continuarea sustinerii din partea acestuia
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Va multumim!Va multumim!