Thursday, April 29, 2010

Why, Grandma...

I thought of Red Riding Hood today, because I saw an older lady up in the clinic up at The Zoo. She was in her 60s. She was referred because of a confusing test result. Remember, in the fairy tale, how Red Riding Hood saw the Wolf who was pretending to be her Grandma. And she said, "Why, Grandma...what big eyes you have!" And the Wolf slyly replied, "The better to see you with, my dear..." And on and on.

Anyway, this lady was like a Grandma. In fact, she could've been a Grandma (I didn't ask her; I know she has 2 kids). I had to tell her that we had gotten her confirmatory test results.

Why, Grandma, yes it is an HIV virus you have.

Wow. What a life-changing day at the doctor's office. She knew that the original test was positive but the confirmatory test was negative. So, the other doctor sent a blood test to see if the lab could see any actual virus in her blood. They saw over 200,000 copies.

At first, she seemed ok with it. Then, I asked her how much she knew about HIV, and whether I should start from the beginning. She lost it. The translator turned to me, looking as helpless as I felt. I put my hand on her leg and said I would do a basic overview today, and I asked her to write down questions over the next 3-4 weeks and ask them at the next visit. She was really strong and pulled herself together. So we went through everything, and I think she'll do great. She's smart, she's organized, and I think she'll take control of her disease rather than the HIV taking control of her.

Hopefully, I'll be the one to see her in a month. It's an immediate bond you build with someone, when you share that diagnosis with them and do the initial education. I'd like to be the one to start her on her meds and encourage her progress. I have a good feeling about her, I think she'll do quite well.

Friday, April 16, 2010

Stage 4

Friday afternoons is Hepatitis Clinic at the VA. I love Hepatitis Clinic. I love the attendings there - both the ID attendings and the liver attendings. I love the patients - let's face it, if you have Hep C, you've probably lived an interesting life. I love the virus - so sneaky, so hard to treat. I may be the only fellow who loves that clinic, but I love it.

Today, I had a patient. He's got Hep C (obviously), but he also has been having nightly fevers, sweats and has had a 20lb weight loss over this time. The ID fellow who saw him 2 weeks ago ordered a bunch of lab tests to try and figure this out. TB was negative, endemic fungal infections were negative. His white blood cells were high, signalling some sort of inflammation/infection. Two random tests came back minimally elevated: Murine Typhus and Q fever.

Now, Murine Typhus holds a special place in my heart. As a resident, I once put a man through a million dollar work up (literally, I saw the financials) before I talked to the ID fellow who recommended I check for Murine Typhus. It was positive. Ever since I've never had a problem humbling myself to ask for help. I also decided that ID doctors were the coolest, smartest people around.

Q fever is a tricky diagnosis. If you don't think of it, you'll never diagnose it. My patient lives in the sticks, so he could've picked it up from whatever farm or wild animals go roaming through his backyard.

I elected to treat him - both diseases are treated the same way - and have him follow up in 3 weeks to see how he's doing. Of course, the treatment of his Hep C is on hold until we get this other diagnosis made.

His liver disease is pretty far gone. His liver feels like my kitchen table, rather than a water balloon. He has tendon contractures in his hands, which is a sign of late liver disease. I would suspect that if I biopsied him, he'd be Stage 4 - cirrhosis. This means we need to treat him now and hope he responds. He's got about a 30% predicted success rate based on his age/virus type/etc, which is admittedly not great. But, I don't think I have time to wait 1-2 years for the newer drugs to come out, because I don't know that his liver will hold up that long. It's going to be hard enough to cure him if he has frank cirrhosis, and the more cirrhotic he gets the worse it'll be.

I didn't tell him all this yet. Better to find out what is causing his acute symptoms, then deal with the chronic liver disease. I'm hoping he'll do well with the Hep C meds, but I'm not terribly optimistic. It will be hard for me to sell him on the treatment when I have such low expectations. Then again, I don't have anything else to offer him at this time.