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NANASI 45: June 2006

NANASI 45: June 2006

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In this issue of NANASI:

  • Case Study: Testicular swelling
  • Q & A: Confirming HIV status in a Child when the Parents Refuse an Antibody Test
  • Very Sick Person: HIV-Associated Nephropathy

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Case Study: Testicular swelling

A 53-year-old man comes to the clinic with swelling of his testicles. The left testicle is somewhat larger than the right, and neither is particularly painful. It is difficult for the man to say exactly when the swelling began because it has been going on for more than a year.

A meticulous examination for inguinal hernia and hydrocele is negative. There has been an unintentional 6 kg weight loss over the past year. There is no cough or diarrhea. The skin and mucous membranes are normal.

  • How would you assess this person?
  • What tests would you request?
  • What medicines would you prescribe?
  • What advice would you offer?

Discuss the case as a group, and then refer to the comments on a later page of this newsletter.


Q & A: Confirming HIV status in a Child when the Parents Refuse an Antibody Test

QUESTION (From a medical doctor in a private hospital in Nairobi): I am caring for a 3-year-old girl who has been in and out of hospital with numerous episodes of chest infections, gastro-enteritis, recurrent otitis media and skin infections. I want to confirm her immune [HIV] status but her parents have declined to give consent. What can I do?

ANSWER: This is a very difficult situation in which many medical practitioners find themselves. The Kenyan Law does not give a doctor authority to over-rule a parent's decision over the choice of treatment in relation to HIV and AIDS, unless it is a matter of life and death. The Law is silent on the issue of consent for HIV testing, and this presents a dilemma for the attending doctor.

There are few options which do not infringe on the Law, each presenting difficulty for the doctor and raising ethical issues for the profession. For example, one might use a combination of clinical features (WHO clinical staging) and a CD4 count (if available) in order to have a reasonable or preliminary hypothesis about the HIV status of the child. 

For example, it could be noted that the child has a weakened immune status if they met the following criteria:

Age 18 months - 5 years

Age 6 years and above

WHO stage 3 - 4
plus
CD4 count < 500

WHO stage 3 - 4
plus
CD4 count < 200

Of course, it is always preferable to do an HIV test to confirm the diagnosis.  Without confirmation, appropriate treatment is difficult to establish.  Using the above option, for example, the underlying cause of the immuno-compromise is not addressed and regardless, the child would not be able to benefit from ARV therapy without the consent of the parent(s).

You should persist in discussing the issue of HIV testing with the parents, ideally through enlisting the aid of a counselor. There is the possibility that with a lot of support and counseling, the parents may agree to have the child tested. Remember that secretly doing the test is illegal and the parents can sue you and the hospital for doing this, even if it was done in the best interests of the child.

Finally, ARVs will only benefit the child if the parents are fully involved and committed to ensuring adherence, nutritional support and timely management of opportunistic infections. Without this commitment, ARV therapy will surely fail and will increase the likelihood of resistant strains of HIV.


VERY SICK PERSON
HIV-Associated Nephropathy

Renal (kidney) failure has been a known complication of HIV infection for many years. A number of renal disorders associated with HIV are well described in the literature. Of these, HIV-associated nephropathy (HIVAN) occurs most commonly. It is now estimated that 10% of people living with HIV will develop HIVAN, progress to end-stage renal disease (ESRD), and will subsequently require renal replacement therapy (eg. dialysis or kidney transplant).

HIVAN most commonly affects black men aged 20 to 64 years and is the third leading cause of ESRD in this group (after diabetes and hypertension). Other consistent risk factors for HIVAN appear to be a low CD4 count (< 200/mm3), being male, and injecting drug use. In most cases, HIVAN progresses to ESRD within 6 months to 1 year after diagnosis but in some cases the progression is much faster.

The development (pathogenesis) of HIVAN is complex and has not been fully clarified. People generally present with nephrotic-range proteinuria, hypoalbuminemia and rapidly deteriorating renal function. Diagnosis is done by a combination of clinical, radiographic, and histologic findings as outlined below:

Clinical characteristics

Proteinuria, most likely nephrotic range (as much as 20g/24 hours)
Rapid progression to end-stage renal disease
Absence of edema and hypertension
Nonspecific urinary sediment, but mild microscopic hematuria and granular casts are occasionally seen
Azotemia (raised creatinine and BUN)

Renal ultrasound 

Large and highly echogenic kidneys
Unchanged kidney size despite worsening renal failure

Renal biopsy - the only way to make a definite diagnosis

Generally reveals collapsing, focal, or global glomerulosclerosis
Microcystic dilatation of the tubules and interstitial cellular infiltrates
Sometimes tubuloreticular inclusions

High-risk people should be screened for asymptomatic proteinuria. Screening should begin with urinalysis. In people whose dipstick proteinuria is 100 mg/dl or higher, the convenient next step is to measure the concentrations of protein and creatinine in a randomly collected urine specimen (protein/creatinine ratio). Renal biopsy is needed in people with significant proteinuria (>0.5 g/24 hr) or progression of renal failure, and when a definitive histological diagnosis will affect therapeutic choices. In the context of working in resource-poor settings, this might not always be possible.

Regardless, there have been isolated case reports showing that people with HIVAN may recover renal function following initiation of antiretroviral therapy (ART).

Treatment

ACE inhibitors (such as captopril) have shown promise in the treatment of HIVAN. They may slow the formation of sclerosis in the kidney and thus slow the progression of renal failure. The proteinuria-decreasing effects of ACE inhibitors have long been recognized, and it seems logical to prescribe an ACE inhibitor for people with HIVAN.

ART has been shown to slow the progression of HIVAN. In clinical studies, many people with HIVAN who received ART were been found to maintain stable renal function, whereas most people who did not required dialysis or died with advanced renal failure. Therefore ART should be considered in those with HIVAN. Many of these medicines are cleared through the kidneys, so caution is required when prescribing them to people with compromised renal function, and appropriate dosage adjustments must be researched.

Although corticosteroid therapy for HIVAN is still advocated by some, this may increase the risk of secondary infection and thus must be used with caution, especially in people who have low CD4+ cell counts. A short course of oral prednisolone 60 mg/day (for 4 weeks on average) can be tried, although the rate of relapse after discontinuation is generally high.

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Answer to the case study:

Painless testicular swelling in a middle-aged man can be caused by tuberculosis. This diagnosis is more likely if the patient is HIV positive, thus an HIV rapid test should be requested. A positive mantoux test will contribute to the diagnosis and should be requested if available. The 6 kg weight loss is worrisome, and might indicate immune-suppression. A CD4 count will help with the assessment of the degree of immune-suppression and will assist in the decision of whether ARVs should be recommended. 

Finally, a surgical review should be requested to support a diagnosis of tuberculosis. This man should be treated for tuberculosis, and it should be noted whether there is any regression in the size of the lesion in response to the TB medicines. His weight and general condition should be monitored regularly. Prophylactic cotrimoxazole is also recommended.

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