Page 33 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 4 of 26 Guideline

TABLE 3: HIV+ concurrent disease and commentary.
Disease Commentary
Cerebrovascular disease: Cerebrovascular accident Comorbid disease, for example, hypertension, diabetes mellitus, renal disease, cardiovascular disease. Hyperlipidaemia with
AZT, ddI, d4T and the PIs
Depression May present with dementia, psychosis
Intoxication and medication Toxicology screen: Alcohol and recreational drugs, efavirenz (EFV) encephalopathy and isoniazid (INH) encephalopathy. Steroid
psychosis.
Progressive multifocal leukoencephalopathy (PML) MRI = white matter lesions. IRIS following ART initiation = gadolinium enhancement on MRI
Metabolic encephalopathy Vitamin B12 and folate deficiency, end-organ failure, antimicrobial encephalopathy, for example, metronidazole
Syphilis Check the blood and CSF syphilis serological tests: VDRL, TPHA
Toxoplasma encephalitis CT and MRI brain scan: Contrast (ring) enhancing lesions; antibody test positive in serum and CSF
HIV encephalitis: Untreated infection CT and MRI: Loss of brain volume, prominent sulci, dilated ventricles, high CSF viral load. NB. Increased cells (lymphocytes)
and marginally raised total CSF protein, with a normal glucose and negative tests for specific pathogens may be pointing to HIV
itself as the cause of the encephalopathy.
HIV encephalitis: Viral escape or CT and MRI as above. HIV viral load in CSF higher than serum viral load. CSF = active (cells, raised protein)
compartmentalisation syndrome 55
CMV encephalitis PCR (viral load) and pp65 antigen in CSF, CMV retinitis and/or ulceration of the gastrointestinal tract (mouth to anus) may
indicate ‘active’ CMV.
Bacterial meningitis, for example, TB meningitis CSF = high protein, low sugar, cells (lymphocytes), TB found elsewhere, for example, LAM test (Urine) or gene XPert positive on
(TBM) 56,57 sputum or CSF; TB culture (blood).
Fungal meningitis, for example, Cryptococcal CSF = high protein, low sugar, cells, CrAg or CLAT positive yeasts seen, crypto culture on CSF positive.
meningitis (CCM) 58,59
Herpes simplex and varicella encephalitis CT and MRI: Focal infarct or bleed, vasculitis on magnetic resonance imaging and angiography (MRA) to confirm a vasculitis,
PCR (viral load) on CSF. Active shingles on the face, for example, ophthalmic division of the Trigeminal nerve, the Ramsay Hunt
Syndrome.
AZT, Azidothymidine; MRI, magnetic resonance imaging; IRIS, immune reconstitution inflammatory syndrome; CSF, cerebrospinal fluid; VDRL, Venereal Diseases Research Laboratory; TPHA,
Treponema pallidum haemagluttinin test; CMV, Cytomegalovirus; PCR, polymerase chain-reaction.
BOX 1: What is medicine? 79 Definition 2. According to the World Health Organization
First I will define what I conceive medicine to be. In general terms, it is to do (WHO):
away with the sufferings of the sick, to lessen the violence of their diseases, and
to refuse to treat those who are overmastered by their disease, realizing that in
such cases medicine is powerless. (Hippocrates, c. 460–370 BCE) Palliative care is an approach that improves the quality of life of
patients and their families facing the problem associated with
Source: Shaner DM. Suspending ethical medical practice. N Engl J Med. 2010;363:1988
life-threatening illness, through the prevention, treatment and
Medical cannabis and palliative care relief of suffering by means of early identification and impeccable
assessment and treatment of pain and other problems, physical,
for the HIV-infected people psychosocial or spiritual. Palliative care:
The science of cannabinoid use as an adjuvant in HIV-related • Affirms life and regards dying as a normal process.
palliative care is new. Although South Africa has recently • Neither hastens nor postpones death.
legalised cannabis for medical use, supporting data are • Provides relief from pain and other distressing symptoms.
largely observational and subjective. Table 3 summarises the • Integrates the psychological and spiritual aspects of patient
current knowledge of cannabinoids in the control of common care.
symptoms, for example, nausea, vomiting, pain, anorexia, • Offers a support system to help patients live as actively as
possible until death.
insomnia, anxiety and depression. However, numerous • Offers a support system to help the family cope during the
‘unknowns’ remain, for example, drug interactions and the patient’s illness and during the experience of bereavement. 2
dosing of a variety of HIV conditions and contexts. This is
still a work in progress that will require updating in Definition 3. End-of-life care: This refers to healthcare, not
subsequent guidelines.
only of a person in the final hours and days of his or her life,
Introduction but more broadly care of those with a terminal condition that
has become progressive and incurable (Wikipedia, accessed
What is palliative care? 07 October 2018). The National Council for Palliative Care,
United Kingdom, states that end-of-life care is given to
Definition 1. According to the National Policy Framework
and Strategy Policy on Palliative Care, Department of Health, persons ‘likely to die within 12 months’. Several commentators
South Africa, 2017–2022: make the point that end-of-life care is not identical to
palliative care, that is, end-of-life care is a final phase within
Palliative care is a multidisciplinary approach to the holistic care
and support of patients and families facing a life-threatening the broader provision of palliative care. Nonetheless, its
illness. Its aim is to improve quality of life while maintaining starting point is sometimes difficult to identify.
dignity from diagnosis to death. For children, the spectrum of
illness includes life-limiting conditions that may progress to The principal goal of palliative care is the relief of suffering.
death or may be severely disabling. Palliative care should be This is done through individualising care – addressing
available to all patients as needed, from birth until death, and symptoms, controlling pain, listening to the patient,
should be accessible at all levels of the health care service.
Palliative care cuts across all health programmes in the delivery responding to fear and anxiety, incorporating families and
1
of services. The care of the dying is as old as the practice of the patient within a competent, professional and resourceful
medicine itself (see Box 1). team, and bereavement support for the patient’s loved ones.
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