Signature Assignment : Case Study

Abstract The case study touches on a hypersensitivity reaction involving Abacavir in patients with HIV. These cause symptoms such as fever, vomiting, nausea, maculopapular rash, malaise, diarrhoea, dyspnoea, and non productive cough. Abacavir (ABC) hypersensitivity reactions are most likely to happen in patients with Introduction

● Explain who the patient is (Age, gender, etc.) ● Explain what the problem is (What were they diagnosed with, or what happened?) ● Introduce your main argument (What should you as a nurse focus on or do?)

A 44 year old male presented to the hospital with complaints of fever and weight loss for one month. Upon examination, he was found to have generalised erythema, oral candidasis, and genital herpetic lesions. He was diagnosed with HIV-1 A 31 year old caucasian male presented to the hospital complaining of recent onset of fever, vomiting, joint pain, muscle aches, sore throat and a fine red rash on his face and arms. His symptoms worsened since the first 2 days and were aggravated from his daily ARVs. He was diagnosed with Immune hypersensitivity reaction to abacavir, which is a drug used for HIV therapy. My goal as a nurse is to be able to subside his symptoms of acute fever, rash, and vomiting. Pathophysiology

● Explain the disease (What are the symptoms? What causes it?) What the patient is experiencing is a Abacavir (ABC) hypersensitivity reaction. This can happen in 4-8% of users, with a majority affecting Caucasians and Asians. The hypersensitivity reaction is caused by his HIV therapy, Abacavir. This has been known to affect individuals expressing the HLA-B 57:01 gene. Some of the symptoms are fever, vomiting, nausea, maculopapular rash, malaise, diarrhoea, dyspnoea, and non productive cough. Symptoms typically appear within the first 6 weeks but may occur anytime during therapy. For this type of hypersensitivity reaction, symptoms are usually non specific and resembling those such as influenza. If abacavir therapy is not ceased once HST is suspected, it may result in an immediate and life- threatening reaction. History

● Explain what health problems the patient has (Have they been diagnosed with other diseases?)

● Detail any and all previous treatments (Have they had any prior surgeries or are they on medication?)

Patient was tested HIV positive three years ago at age 28. He had no history of traveling and coming in contact with anyone with similar symptoms. Some of his previous treatments was that he started his first line ARV therapy – Stavudine (d4T), Lamivudine (3TC) and Efavirenz (EFV), which he continued to take until his last appointment 5 weeks ago. He also noticed that he had gained 3kg over the last three months. He was not concerned by high weight gain, but noticed that he developed a bulge on the back of his neck due

to his T-shirt feeling uncomfortable and tight in that area. He also noticed that his face was becoming gaunt and his cheekbones were becoming more prominent. This was assessed as being caused by d4T, which is known to cause lipodystrophy. Because of this, d4T was replaced with Abacavir. Nursing Physical Assessment

● List all the patient’s health stats in sentences with specific numbers/levels (Blood pressure, bowel sounds, ambulation, etc.)

Checked five weeks prior: CD4 count: 185 cells/µL viral load measurement: 20800 copies/mL. Vitals Temperature 38.0 ℃ Blood pressure: 135/78 Heart rate: 105 Respiratory rate: 20 General Mild pallor No jaundice Cervical lymphadenopathy No edema Head and neck Fine maculopapular rash on face Red, slightly eodematous pharynx Sunken cheek bones Buffalo hump on the back of the neck Chest Trachea centrally located No wheeze Lung fields clear bilaterally No other added breath sounds

Examination Value

WBC 4.8

HB 14.2

Platelets 217

CRP 15

NA 137

K 3.9

Cl 100

CO​2 19

Urea 6

Creatinine 108

Corrected Calcium 2.16

Phosphate 1.4

Magnesium 1.1000000000000001

Total protein 73

Albumin 41

Total bilirubin 6

Direct bilirubin 2

ALP 20

Gamma GT 20

ALT 103

AST 22

CD4+ 396

Viral Load <25

Blood culture negative

Related Treatments

● Explain what treatments the patient is receiving because of their disease For treatment, the patient stopped receiving ARV medication and bactrim

In our patient, all ARV medication and bactrim was stopped and supportive care was provided until the symptoms resolved. Although he had tolerated bactrim well since initially starting ARVs it was also stopped at this time as it was not clear what was causing the reaction. Genetic screening was also performed on the patient. (____). The patient was also offered therapy such as intravenous hydration. Also Genetic screening was Immunopaedia.org.za conducted for a suspected ABC hypersensitivity reaction. He was found to be positive for HLA-B*5701, which provided the supporting evidence for the ABC hypersensitivity reaction. Although ideally an HLA screen should have been performed before initiating ABC, it was thought reasonable by the treating clinician to initiate therapy with abacavir along with appropriate clinical counseling and monitoring for any signs of hypersensitivity. Nursing Diagnosis & Patient Goal

● Explain what your nursing diagnosis is (What is the main problem for this patient? What need to be addressed?)

● Explain what your goal is for helping the patient recover (What do you want to change for the patient?)

The main problem for the patient is that there is that he is having an adverse reaction to the drug abacavir. The aspects that should be addressed is to help him get rid of his fever and rash and monitor if he has worse symptoms. In order to help the patient recover, the drug should be discontinued and supportive care should be provided.

Nursing Interventions

● Explain how you will accomplish your nursing goals, and support this with citations (Reference the literature)

As a nurse, it is important to continue to monitor the patient and check often for any reoccuring symptoms. Intravenous What should be avoided is using corticosteroids because it may mask the development of symptoms. However, antihistamines can be used for the patient’s comfort. (Hetherington 2001). Evaluation

● Explain how effective the nursing intervention was (What happened after your nursing intervention? Did the patient get better?)

The nursing intervention was successful because the symptoms of the hypersensitivity reaction were able to subside. These symptoms improve in 2 days. Recommendations

● Explain what the patient or nurse should do in the future to continue recovery/improvement

Some goals in nursing is to educate the patient and any family about the condition. It is important to advise that hypersensitivity reactions can lead to death. I also will tell him that he should stop taking medication and notify me once he notices any signs of another hypersensitivity reaction or

reconstitution symptoms (​Quiring, ​2020). It is also advised to never re-initiate any product with abacavir. In order to prevent him from taking the product again, it is advised to return Abacavir to the pharmacy (Hetherington, 2001). Conclusion References A case of acute fever, rash and vomiting. ​Immunopaedia.org.za.

https://www.immunopaedia.org.za/clinical-cases/hypersensitivity/a-case-of-acute-fever-r a

sh-and-vomiting/?print=pdf Quiring, Courtney, et al. "Abacavir/dolutegravir/lamivudine." ​Davis's Drug Guide​, 16th ed., F.A. Davis Company, 2020. ​Nursing Central​, nursing.unboundmedicine.com/nursingcentral/view/Davis-Drug-Guide/110156/all/abacavir_dolu tegravir_lamivudine. Hetherington et al. Clin Ther. 2001; 23:1603-1614