The trainees presentations were a highlight of the conference for me - some fascinating cases, presented superbly with an audience including some great HIV clinicians made for a stimulating and highly educational session. It would have been easy to continue the discussion on any of these cases for a good few more hours.
The first case, from the Alfred Hospital was of a young man recently arrived in Australia who presented with a rash and pulmonary infiltrates. The rash was eventually found to be histoplasma - an important diagnosis to consider, although much more common in other parts of the world, locally acquired cases have been reported.
The next case, from Perth, was of another visitor, this time from Zimbabwe, who was diagnosed with HIV after presenting with sinus pain. Investigations found haemophagocytic lymphohistiocytosis, and she was diagnosed with orbital NK/T cell lymphoma. Due to her status as a visitor, there were issues associated with payment. Whilst her HIV care was paid for as an STI according to a state government undertaking, therapy for the cancer proved an entirely different matter. She was given second line therapy in order to contain costs. On her return to Zimbabwe, again HIV treatment was easily available, however the treatment of the cancer was again not possible and she died 3 months after her return.
A case of gummatous tertiary syphilis, presenting as lesions on the back and arm was presented from inner city Sydney. Again, advanced HIV, known this time for a number of years but untreated, was present, however in this case, syphilis had also been diagnosed on numerous occasions over recent years but remained only partially treated. The case presented numerous issues including diagnosis and management of tertiary syphilis, the difficulties in managing patients with psychiatric comorbidities as well as complex social circumstances and itinerancy. This was a sobering reminder of the difficulties that are faced in clinical practise, and the presentation ended with the case being unresolved (patient absconded with partial syphilis treatment and having not picked up ongoing HIV medication scripts).
Finally, from the Royal Melbourne Hospital, another late presenting individual with advanced immunosuppression, newly diagnosed with HIV and started on treatment, presented to hospital with cryptococcal meningitis, and, despite treatment, deteriorated with multiorgan failure and decreased conscious state in ICU. Fortunately, he recovered to be discharged well form hospital a number of weeks later. The analysis focused on the reasons behind the deterioration in health after treatment commencement, with the most likely explanation believed to be unmasking cryptococcal IRS. An important question about whether rates of IRS are increased on INSTi was raised, with George Behrens- guest from Germany and one of the judges of the session, announcing an impending clinical trial in severely immunocompromised new presenters starting on treatment , comparing rates of IRS on treatment with PIs compared with integrase inhibitors.
In addition to the medical complexities of the cases, common themes including late presentation, still a not infrequent problem, and the difficulties in management associated with challenging socio-demographic circumstances, including itinerancy, psycho-social issues, and medicare -eligibility.
Plenty to think about.