Clinical meet


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Clinical meet

  1. 1. Clinical meet Dr.H.B.Prasad Unit A case of PLHIV with Paraplegia Dr.Ajitkumar K.Jadhav JR (II) Date :- 2 nd April , 2011
  2. 2. HISTORY <ul><li>42 yr , male , Labourer , r/o Pune . </li></ul><ul><li>K/c/o PLHIV since last 1 ½ yrs on ART (ZL+ Efa ) </li></ul><ul><li>CD4- 120/cmm </li></ul><ul><li>Chief complaints </li></ul><ul><ul><li>Inability to walk - 2 months </li></ul></ul><ul><ul><li>weakness started in both lower limbs, associated with looseness , progressed to bed ridden state in last 15 days </li></ul></ul><ul><ul><li>Fever - on and off since 1 month </li></ul></ul><ul><ul><li>moderate grade , associated with night sweats , relieved with antipyretics </li></ul></ul><ul><ul><li>Easy fatigability and exertional dyspnoea – 1month </li></ul></ul>
  3. 3. <ul><li>H/o Pulmonary Kochs 6 months back ,was still on AKT </li></ul><ul><li>No h/o </li></ul><ul><ul><li>trauma to back </li></ul></ul><ul><ul><li>Similar episode in the past </li></ul></ul><ul><ul><li>Decreased sensations below the level of umbilicus </li></ul></ul><ul><ul><li>No bowel/bladder complaints </li></ul></ul>
  4. 4. Examination <ul><li>General Examination: </li></ul><ul><ul><li>Avg. built ,poorly nourished </li></ul></ul><ul><ul><li>Ht -157 cm ,Wt – 40 kg ,BMI - 17 </li></ul></ul><ul><ul><li>Conscious ,oriented </li></ul></ul><ul><ul><li>Febrile </li></ul></ul><ul><ul><li>Pulse - 102/min </li></ul></ul><ul><ul><li>BP - 110/70 mmHg </li></ul></ul><ul><ul><li>Pallor ++ </li></ul></ul><ul><ul><li>Multiple matted lymph nodes in Cervical region ,1 cm in size </li></ul></ul><ul><ul><li>No oedema /icterus / cyanosis /clubbing </li></ul></ul>
  5. 5. <ul><li>Systemic Examination : </li></ul><ul><ul><li>CVS – S 1 S 2 heard well, Tachycardia </li></ul></ul><ul><ul><li>RS – Breath sounds were decreased in Rt. IAA with stony dull purcussion note ,with no adventious sounds </li></ul></ul><ul><ul><li> Rest lung fields were clear </li></ul></ul><ul><ul><li>P/A –Soft , Liver -palpable 3 cm , firm </li></ul></ul><ul><ul><li>Spleen - Palpable 5 cm , firm </li></ul></ul><ul><ul><li> No free fluid </li></ul></ul><ul><ul><li>CNS – </li></ul></ul><ul><ul><li> Higher functions and Cranial nerves were normal </li></ul></ul><ul><ul><li> Motor system </li></ul></ul><ul><ul><li>Nutrition – mild wasting was present </li></ul></ul><ul><ul><li>Tone –Normal in both Upper Limbs and decreased in both Lower Limbs </li></ul></ul>
  6. 6. <ul><li>Power - Grade V in both upper limbs </li></ul><ul><li> Grade II in both lower limbs </li></ul><ul><li>Co-ordination – Normal in upper limbs </li></ul><ul><li> Could not be tested in lower limbs </li></ul><ul><li>Reflexes – DTR ++ in both upper limbs </li></ul><ul><li>+++ in both lower limbs </li></ul><ul><li> Superficial- lower abdominals were absent </li></ul><ul><li> Plantars were both extensors </li></ul><ul><li>Sensory system </li></ul><ul><li>Pain , Temp,Touch </li></ul><ul><li>Joint position & Vibration </li></ul><ul><li>Spine showed gibbus at the level of T-8 vertebra , Which was tender </li></ul>decreased below the level Umbilicus around T 12
  7. 7. <ul><li>Young male PLHIV on ART , with pulm kochs on AKT with anemia (likely AZT induced ) with chronic progressive paraplegia , with sensory involvement ,without bowel / bladder involvement and with lymphadenopathy and hepato-splenomegaly </li></ul><ul><li>Differentials </li></ul><ul><li>? </li></ul>
  8. 8. <ul><li>Compressive myelopathy involving thoracic spine likely </li></ul><ul><ul><li>Potts spine </li></ul></ul><ul><ul><li>TB myelitis </li></ul></ul><ul><ul><li>Disseminated hematological malignancy like Lymphoma </li></ul></ul><ul><ul><li>bacterial spinal abscess </li></ul></ul>
  9. 9. Investigations <ul><li>Hb- 3.7 gm % </li></ul><ul><li>MCV – 112 fl </li></ul><ul><li>TLC – 9700/ cmm </li></ul><ul><li>DLC – P 67 L 26 E 03 M 04 B 0 </li></ul><ul><li>mild anisocytosis,normocytes 2 +, microcytes 1 + ,few macrocytes ,polychromasia 2 +, moderate hypochromia </li></ul><ul><li>Platelet count - 2.48 lac </li></ul><ul><li>Retic count -8 % </li></ul><ul><li>ESR- 57 mm at the end of 1 hr </li></ul><ul><li>Sr. Creatinine 1.7 mg % </li></ul><ul><li>Total bilirubin – 2.5 mg % , Direct 1.6 mg% </li></ul><ul><li>SGOT/SGPT – 45/39 (IU/L) </li></ul><ul><li>Total proteins – 5.4 gm % </li></ul>
  10. 10. Chest Xray <ul><li>-Right sided loculated </li></ul><ul><li>Pleural effusion with </li></ul><ul><li>Underlying lung collapse </li></ul><ul><li>pleural thickening </li></ul><ul><ul><ul><li>USG abdomen </li></ul></ul></ul><ul><ul><ul><li>Hepatosplenomegaly with mild ascitis </li></ul></ul></ul><ul><ul><ul><li>Rt psoas abscess with echogenic mesentry </li></ul></ul></ul><ul><ul><ul><li>B/L enlarged echogenic kidneys </li></ul></ul></ul>
  11. 11. X ray Thoraco-lumbar spine <ul><li>Showing compression collapse of D9-D10 vertebrae with anterior wedging in lateral film </li></ul>
  12. 12. MR Scan of dorsal spine reveals :- <ul><li>Altered marrow signals appearing hypointense on T1 and hyperintense on STIR images are noted in D6 , D7 to D8 & 9 vertrbral bodies and posterior neural arches of D9 & D10 vertebrae. s/o infiltration and inflammation in vertebral bodies </li></ul><ul><li>Pre and bilateral paravertebral T2 hyperintense soft tissue component extending from D3 to D11 vertebral bodies ( abscesses ) with anterior epidural soft tissue seen from D9 to D10 </li></ul><ul><li>Swollen cord with T2 hyperintense signals longitudinally along D8/10 vertebra suggestive of cord edema / infective myelitis. </li></ul><ul><li>Loculated thick walled right pleural effusion –? empyema. </li></ul>In view of reduction of intermediate disc spaces , associated pre & para spinal abscesses, possibility of multicentric tuberculosis is more likely, needs histopathological corelation
  13. 13. <ul><ul><ul><li>Patient was continued on </li></ul></ul></ul><ul><ul><ul><li>- ART (LS + Efa ) </li></ul></ul></ul><ul><ul><ul><li>- AKT with addition of steroids,hematinics . </li></ul></ul></ul><ul><li>The question that remained unanswered was why did patient develop paraplegia despite being on AKT </li></ul><ul><li>??? </li></ul>
  14. 14. <ul><li>Meanwhile we received a PBS report from pathology dept stating that </li></ul><ul><li>RBC : mild anisocytosis , microcytes 1 + ,few macrocytes polychromasia 2 +, moderate hypochromia </li></ul><ul><li>TLC : 60000 /cmm </li></ul><ul><li>DLC : </li></ul><ul><li>Neutrophils :- 35 % </li></ul><ul><li>Monocytes :- 5 % </li></ul><ul><li>Lymphocytes – 5 % </li></ul><ul><li>Abnormal cells – 55% abnormal cells are large cells with High N:C ratio , folded nucleus and scanty , bluish cytoplasm. Few cells show prominent nucleoli. Suggestive of Lymphoid cells </li></ul><ul><li>Platelet : appear scattered and reduced. </li></ul><ul><li>Parasites : Not seen in present smear </li></ul><ul><li>Advice : Follow up with bone marrow aspiration . </li></ul><ul><li>Special stain report follows. </li></ul>
  15. 15. <ul><li>BM Aspiration </li></ul><ul><li>Hypercellular marrow with diffuse infiltration by large lymphoid cells of heterogenous morphology </li></ul><ul><li>Erythroid series : Megaloblastic erythropoiesis </li></ul><ul><li>Granulocyte series : relatively depressed </li></ul><ul><li>Myeloid / Erythroid ratio : 9:1 </li></ul><ul><li>Differential counts : </li></ul><ul><li>Blast like cells - 70 % Basophils -00 % </li></ul><ul><li>Promyelocytes – 01% Eosinophils -01% </li></ul><ul><li>Myelocytes - 03% Lymphocytes- 04% </li></ul><ul><li>Metamyelocytes -02% nRBC : 10% </li></ul><ul><li>Band cells – 03% Plasma cells -03% </li></ul><ul><li>IMPRESSION : </li></ul>High grade Non –Hodgkin’s Lymphoma (? Burkitt’s Lymphoma )
  16. 16. Final Diagnosis <ul><li>Patient of PLHIV with Pulmonary Koch’s(On ART and AKT ) with High grade NHL (? Burkitt’s Lymphoma ) with AZT induced anemia with compressive myelopathy most likely due to TB and Lymphoma </li></ul>
  17. 17. <ul><li>As patient was critically ill ,and non affording , immunophenotyping and cytogenetics studies was not possible </li></ul><ul><li>As a desperate measure we started him on chemotherapy ---Cyclophosphamide , Vincristin , Adriamycin and Prednisolone , as per Hemato -oncologist ‘s opinion </li></ul><ul><li>During the course of treatment pt developed altered sensorium, for that Lumbar puncture was tried but no fluid could be tapped . </li></ul><ul><li>Unfortunately we lost the pt during the course of illness </li></ul><ul><li>(Day 2 of chemotherapy) </li></ul>
  18. 18. Discussion
  19. 19. <ul><li>Spinal cord involvement in HIV patients </li></ul><ul><li>Myelopathy is seen ~20% of patients with AIDS, often as part of </li></ul><ul><li>HIV encephalopathy </li></ul><ul><li>CMV infection causes Progressive Lumbosacral Polyradiculopathy </li></ul><ul><li>HTLV-I-associated myelopathy (HAM) -Tropical spastic paraparesis </li></ul><ul><li>Neurosyphilis (Meningeal, Meningovascular , General paresis , Tabes dorsalis ) </li></ul><ul><li>Infection with herpes simplex or varicella-zoster , EBV (Rapidly progressive symmetric lower limbs weakness) </li></ul><ul><li>TB </li></ul><ul><li>Lymphoma </li></ul>
  20. 20. <ul><li>Lymphomas in HIV </li></ul><ul><li>Lymphoma is a late manifestation of HIV infection, generally occurring in patients with CD4+ T cell counts <200/ uL </li></ul><ul><li>90% are B cell in phenotype, and </li></ul><ul><li>half contain EBV DNA </li></ul><ul><li>Three main categories </li></ul><ul><li>Grade III or IV immunoblastic lymphoma :- </li></ul><ul><ul><li>60 % of all lymphomas , </li></ul></ul><ul><ul><li>associated with pleural, pericardial, and/or peritoneal effusions in the absence of discrete nodal or extranodal masses, </li></ul></ul><ul><ul><li>HHV-8 DNA sequences have been found </li></ul></ul><ul><li>Burkitt's lymphoma :- 20% cases , Small noncleaved cell lymphoma </li></ul><ul><li>Primary CNS lymphoma . :- </li></ul><ul><ul><li>Mostly positive for EBV , </li></ul></ul><ul><ul><li>generally presents with focal neurologic deficits, including cranial nerve findings, headaches, and/or seizures. </li></ul></ul>
  21. 21. <ul><li>Burkitt’s lymphoma </li></ul><ul><li>30%–40% of non-Hodgkin’s lymphoma   in HIV +  patients </li></ul><ul><li>Burkitt’s   lymphoma was estimated to be 1,000 times more common in HIV +  individuals than in the general population   </li></ul><ul><li>The diagnosis of Burkitt’s lymphoma in an HIV +  individual   often represents the first AIDS-defining criterion. </li></ul><ul><li>HIV is involved in lymphomagenesis   via </li></ul><ul><ul><li>cytokine deregulation </li></ul></ul><ul><ul><li>chronic   antigenic stimulation </li></ul></ul><ul><ul><li>decreased immune surveillance </li></ul></ul><ul><li>Lymphoma often involves lymph nodes, bone marrow, and extranodal   sites, most often in the abdomen , liver ,CNS and lungs </li></ul><ul><li>Burkitt,s lymphoma in HIV is very aggressive tumour with poor response to chemotherapy , difficult to achieve complete remission , and less proven response to Rituximab .   </li></ul>
  22. 22. <ul><li>Multicentric Castleman's disease – </li></ul><ul><li>This is an HHV-8 associated lymphoproliferative disorder , usually associated with generalized lymphadenopathy, hepatosplenomegaly, and systemic symptoms of fever, fatigue, and weight loss. </li></ul>
  23. 23. <ul><li>Treatment recommendations: </li></ul><ul><li>Systemic non-Hodgkin’s lymphoma </li></ul><ul><li>All patients with CD4 <100/mm 3 :  Low-dose chemotherapy </li></ul><ul><li>CD4 >100/mm 3 :  Consider standard-dose chemotherapy in selected patients. </li></ul><ul><li>Antibiotic prophylaxis  for P. carinii in all patients. </li></ul><ul><li>Meningeal prophylaxis  for those with small noncleaved histology, bone marrow involvement, paranasal sinus involvement, or epidural disease. </li></ul><ul><li>Antiviral therapy: </li></ul><ul><li>Combination antiviral therapy should be continued with chemotherapy </li></ul><ul><li>Zidovudine is not recommended due to risk of overlapping myelosuppression. </li></ul><ul><ul><li>Rituximab, a monoclonal anti-CD20 antibody. </li></ul></ul>
  24. 24. <ul><li>THANK YOU </li></ul>