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CASE PRESENTATION

O
N

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

CHIEF COMPLAINTS

Breathlessness on exertion since 20 days


Giddiness and fever since 20 days
Headache
Fatigability
Body pains

On Examination
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:22-10-2011
DATE OF DISCHARGE:2-11-2011

History
FAMILY HISTORY:
Wife - HIV positive
3 childrens:13 years/F-Positive
12years/M-Positive
3 years/M-Negative
SOCIAL HISTORY:
Patient is a driver
He is smoker and alcoholic
He quits alcohol 3 months back

PAST MEDICAL AND


MEDICATION HISTORY
ART-Anti
retro viral
therapy
AZTZidovudine
3TCLamivudine
NVPNevirapine
DT4Stavudine

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 with
Ramipril 1.25mg once daily

CD4 Count of Patient


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

S
p

B
L
O
O
D

Estimated. compound

Normal value

Observed value

22-1-2011

23-1-2011

24-1-2011

Hb

11-16.5g/dl

5.1g/dl

5.18g/dl

6.5g/dl

TC

350010000/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

Tests

R
F
T

L
F
T

Specimen

B
L
O
O
D

Est. compound

Normal values

Observed values

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

135148mmol/l

139.9mmol/l

3.5-5.3mmol/l

4.32mmol/l

Cl

98-107mmol/l

108mmol/l

LDH

150-330U/l

343

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

36142mml/ml

76.1mml/ml

Sr.Albumin

3.5-5.0g/dl

4.5g/dl

MP: Negative

Urine Analysis
Urine albumin-Trace
Sugar-Nill
Micro, Pus cells < 2
Epithelial cells few <5

24-102011
Vit-B12-549.9pg/ml

PERIPHERAL SMEAR
Normocytic, normochromic RBC
TC-2500/cum
Sputum AFB-Negative
Platelets are adequate

NORMAL
NORMAL COUNT:
COUNT
Viral load : <46c/ml
<200c/ml
ELISA:
ELISA
0.089-Non reactive
>0.7 Reactive

DIAGNOS
DIAGNOSIS:
IS
HTN-Newly diagnosed
Zidovudine induced anaemia
Blood transfusion done on 22-10-2011
and 2-10-2011

DIAGNOS
IS

ZIDOVuDInE
INDUCE
ANAEMIA

ZIDOVUDINE INDUCED
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

GOALS OF

ART ARE

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/L or more within 2 to 4 months.
Reference: Standard treatment guidlines-A manual for medical therapeutics ,Third Edition
by sangeetha sharma

PRESENT MEDICATION
DRUG

DOSE

FREQ

R.O.
A

22

T.Paracetamol

650mg

TID

PO

T. Thiamine

75mg

Stat

PO

T. Ramipril

1.25mg

OD

PO

T.
Trimethoprim+
Sulfamethaxaz
ole

800mg+160mg OD

T.Iron and
Folic acid

200mg+0.5mg

DT3/3TC/NVP

40mg+300mg
+
200mg

23

24

25

PO

OD

PO

BD

PO

THERAPEUTIC

OUTCOME

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

DISCHARGE MEDICATIONS
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 .

DRUG RELATED PROBLEMS

NRTIS are associated with lactic acidosis,


lipoatropy and peripheral neuropathy
which leads to non-adherence to the long
term therapy.

MONITORING
PARAMETERS
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.

PATIENT COUNSELLING
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

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