Page 40 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 11 of 26 Guideline

patients in LMICs and in particular to poor people – including fluid retention, proximal myopathy, confusion and psychosis.
many poor or otherwise vulnerable people in high-income Testosterone has benefited hypogonadal individuals with
countries – is a medical, public health and moral failing and a fatigue and the stimulants, modafinil and armodafinil, have
46
travesty of justice. (p. 1391) had success in reducing fatigue in small RCTs, but caution is
42
31
advised in view of limited data and the risk of drug abuse.
The Commission notes that the 10 health conditions that Invasive procedures, such as nasogastric feeding and
result in the largest numbers of patients seeking palliative percutaneous endoscopic gastrostomy, are discouraged at the
care in LMICs, namely, malignancy, cerebrovascular disease, end of life but may be considered where a reversible condition
lung disease, injuries, TB, premature birth, HIV, liver disease, has been identified. Ensure good nursing, keep the oral mucosa
non-ischaemic heart disease and dementia, also account for clean, moist and wet and mobilise the indigent patient where
about 95% of days of serious health-related suffering reported possible. Avoid bedsores and treat oral thrush with topical
in these countries. nystatin drops 2 mL – 5 mL ‘swish and swallow’ five times a
day or oral fluconazole 50 mg – 100 mg daily until the infection
Fatigue, weakness, anorexia and wasting (see clears. If oesophageal candida is diagnosed, give oral
Table 3-A4, Appendix 4) fluconazole 100 mg – 200 mg daily for 7–10 days. A short
Increased resting energy expenditure (REE) is a persistent course of IV amphotericin B can be considered if the patient is
accompaniment of HIV infection despite the use of ART. In unable to swallow the fluconazole. Treat oral and oesophageal
43
situations of inadequate food intake and altered food Herpes simplex aggressively, prescribe oral acyclovir (public
metabolism, weight loss may become severe. With every 1% sector) or valaciclovir (private) if the infection is mild and
increase in unintentional weight loss from the baseline confined to the mouth and IV acyclovir for disease that is
measurement, there is a detectable increase in the risk of extensive, virulent or involves the oesophagus. Continue
death of the HIV-infected patient. The lower the BMI, that treatment until the infection has cleared, usually for 7–10 days,
44
2
is, below the normal value (BMI 18 kg/m – 20 kg/m ), the and control the pain that often requires strong analgesia, for
2
45
greater the risk. example, codeine or tramadol. Food should be liquidised or
very soft to minimise oral pain while the infection is acute.
Possible clinical conditions include:
• Disease of the mouth and upper gastrointestinal tract Dyspnoea and cough (see Table 3-A4, Appendix 4)
(GIT), for example, oesophageal candidiasis and The anatomic connections that control the cough reflex link
cytomegalovirus (CMV) infection and ulceration. the upper and lower airways to afferent and efferent neural
• Anorexia. Consider medication, tumour and occult connections within the brain. Disease at any of these sites
46
infection, for example, TB (drug-resistant TB) or MAC. may be responsible for cough; however, in HIV-infected
Drugs: Chemotherapy, lopinavir/ritonavir. patients, cough usually directs attention to the lung. An acute
• Food insecurity. Particularly among refugees, migrants cough lasts from a few days to a few weeks and a chronic
and the poor. cough lasts for ≥ 8 weeks.
47
• Malabsorption, for example, chronic diarrhoea, GIT-TB
or MAC, tumour of the GIT. Send repeated stool samples Symptoms of dyspnoea and cough include the following:
(× 3) for parasites: Cryptosporidia, Cystoisospora spp.
Poorly controlled HIV infection = HIV enteropathy. • Bacterial pneumonia: Productive cough, fever, chest
• Infection, particularly end-stage HIV, TB, MAC and CCM. pain, sudden onset and acute history. Aspiration
• Disseminated tumour. pneumonia is frequent at the end of life.
• Hormonal deficiencies, for example, Addison’s disease, • Pulmonary TB (PTB): Productive cough, haemoptysis,
hypothyroidism and hypogonadism. chest pain, fever, night sweats, weight loss, chronic
history or past history of TB, and TB contact history.
(Bold indicates conditions that are frequent among the HIV- • PJP: A dry incidental chronic cough, worsening dyspnoea
infected patients.) with effort, later dyspnoea at rest, severe hypoxia at rest,
worsens with exertion, little or no fever, minimal chest
Management: The HIV clinician will look for treatable causes pain, profound fatigue and exhaustion, tachycardia and
but as the patient approaches death, symptomatic treatment unrelenting tachypnoea. Often a bedside diagnosis!
will take priority. Start ART if the patient is treatment naive or ß PJP: Poor prognosis. The persistence of hypoxia or
check for resistance if on ART and the VL is detectable. respiratory failure, tachypnoea and tachycardia
Glucocorticoids, for example, dexamethasone 2 mg daily po or despite treatment, no decrease in baseline LDH level
IV–4 mg daily po or IV, can be considered at the end of life as with treatment, worsening of the chest X-ray (CXR)
the risk of additional immunosuppression is unlikely to on treatment, elevated Acute Physiology and Chronic
influence the outcome. Steroids are often given to stimulate the Health Evaluation (APACHE) II score. 48,49
appetite and/or to counter the fatigue and weakness of the ß PJP: Prevention. Initiation onto ART soon after the
final illness. Vigilance is indicated if steroids are given for a initial infection with HIV and prophylactic use of
prolonged period of time and patients should be monitored trimethoprim-sulfamethoxazole with all baseline CD4
for hypertension, hyperglycaemia, gastrointestinal bleeds, cell counts < 350 cells/mm are recommended. 50,51
3
http://www.sajhivmed.org.za 33 Open Access