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The UC San Diego AntiViral Research Center sponsors weekly
presentations by infectious disease clinicians, physicians and
...
Cases
Gigi Blanchard, MD
July 19,2013
DK
• DK is a 36yo Indian woman with newly diagnosed
HIV who presented w/ fever and progressively
worsening back pain
• Tes...
Chest imaging 7/12
7/12 Admission for pna
• Ruled out for TB with 3 negative AFB smear/cx
• Cryptococcal Ag & Histo negative
• Cocci CF anti-...
7/12 Admission w/
anaphylaxis
• Another admission for fever (104.6) and cough
• This admission complicated by anaphylaxis
...
Outpatient F/U
• CD4 = 264 – up from 172
• HIV VL = 207 – down from 400K
• CT chest 8/12:
• Partial resolution of diffuse ...
8/12 Admission
• Daily fever (102.6), back and leg pain
• No weakness but pain is so bad can’t walk and now has a
rash to ...
• ALL:
• Augmentin
• Ceftriaxone
• Cipro
• Doxycycline
• Fluconazole
• SMP/TMZ
• Azithromycin
• Morphine
• Micafungin
• Sh...
T 102.5 P 104 BP 118/76 RR 16
• GEN: tearful but in no other distress
• HEENT: OP clear; no icterus
• PULM: CTA B/L
• CV: ...
• Na 131, K 3.9, Cl 99, Bicarb 19, BUN/Cr nl
• AST/ALT: 44/45, ALB 3.8
• WBC = 8.9, H/H = 9.9/30; Plt = 384
• S 36 L 51 E ...
MRI Lumbar Spine
8/12 Admission
• IR unable to aspirate the SI joint but did do a wash-
out
• WBC 90 (44% PMNs, 44% Lymphocytes, 4% Eos,
8%...
Admission Sacroiliitis
• Brucella Ab <1:20
• Bartonella Ab < 1:64
• Strongyloides Ab 0.03 negative
• Lyme 0.26 negative
• ...
8/12 Admission
• 8/13/12 Cocci CF Anticomplementary; ID negative
• Numerous bacterial, AFB and fungal cx negative from
blo...
A New Result
• 8/18/13 Cocci CF + 1:16
• Total body bone scan negative
• CSF studies are normal/negative
• Desensitized to...
18
Case DK
July 3-5 July 20 Aug 13 Aug 18 Aug 24
Cryptococcal
antigen (serum)
Negative Negative Negative
Histoplasma
antig...
Coccidioides
Coccidioidies: forms
• Endemic to arid SW
• Arizona, California,
Nevada, New Mexico &
Utah
• Parts of Central and South
America
Clinical Manifestations
• 50-70% of infections are asymptomatic or so mild
that they don’t come to medical attention
• Usu...
Clinical Manifestations
• Early respiratory infection
• Sx develop 7-21 days after exposure
• Onset is usually subacute bu...
Pulmonary Findings
• Unilateral infiltrates, hilar adenopathy & effusions
• Nodules – Peripheral & Solitary
• Cavities ~ 8...
ExtraPulmonary
Dissemination
• Only 0.5% in general population
• Much more common in immunosuppressed
• AIDS (CD4 < 100)
•...
ExtraPulmonary
Dissemination
• Skin: maculopapular lesions to ulcers to abscesses
• Joints and bones – any joint can be in...
Diagnosis
• Delayed-type hypersensitivity testing
• + for life
• Anergy: May be negative during active infection
• Direct ...
Diagnosis: Direct exam/cx
• Identifying spherules in a specimen
• Sputum is not infectious
• Can’t be detected by Gram Sta...
Serologic Diagnosis
• + Antibodies in serum, CSF or other fluid
• Highly specific
• Even minimally reactive results are si...
Immunodiffusion
• Antigen is incorporated into
the gel or agar
• Serum (antibody) is added
to wells, which then diffuses
t...
32
Complement Fixation
Disease
No
disease
Control
(no test
antigen)
Notes
Control
(no test antigen)
Heat (remove
native
co...
Back to DK
• She remains afebrile
• Back pain due to anterolisthesis remains severe
• Re-admitted 10/12 for out of control...
• A diagnostic procedure is performed
Non-Hodgkin’s Lymphoma!!
Terry
• Terry is a 41yo AA M-to-F with a CD4 = 196 (12%)
, VL = 167 in 6/11 who presented to UCSD’s ED
10/12 with several ...
Terry
• Abd pain – epigastric x 1 week
• + N/V; No D or constipation
• Not ass’d with eating; no radiation
• Wakes her up ...
Terry
• ROS:
• + anorexia with ~ 20lbs weight loss over 2 mo
• F x 2 weeks – as high as 110!; NS x 2 week
• No HA; No visu...
Terry
• PMHx
• HIV, dx’d in ‘03
• Syphilis
• Meds: None
• ALL: NKDA
• Shx:
• on disability
• No tob, etoh
• Smoked meth 2 ...
T 97 P119 BP 106/70 RR 22 100%
• GEN: thin AAM in NAD
• HEENT: poor dentition but no thrush or lesion
• PULM: CTA B/L
• CV...
Labs
• Na = 131, BUN/Cr = 22/0.17
• Cl = 89, Bicarb = 17
• SGOT/SGPT = 53/17; albumin = 2.6
• AG = 27.5; Lactate = 91.1
• ...
Labs
• WBC = 6.8; H/H = 10.9/33.4; Plt = 232
• MCV = 76.1, RDW = 20.9
• S 77; B 3; L 10
• UA: 1.027, 1+ protein; no glu; m...
Bedside Echo
Cardiac Masses
• Infections/endocarditis
• Bacteria
• Mycobacteria
• Fungi
• Candida
• Aspergillus (intracardiac masses ha...
Cardiac Masses
• Thrombi (cluster of grapes; trapped in the chords)
• Structural Abnormalities
• False tendons (ventricula...
Cardiac Tumors
• Sx depend on size and location
• Chest pain, syncope, heart failure
• Arrhythmias, murmurs, pleural effus...
Primary Cardiac Tumors
• Myxoma
• Most common benign tumor
• 1/3 of all primary cardiac tumors
• 75% involve the LA at the...
Primary Cardiac Tumors
• Sarcoma
• Most common malignant primary cardiac tumor
• ~ 40% are angiosarcomas
• Usually in the ...
Primary Cardiac Tumors
• Kaposi’s Sarcoma
• Cardiac involvement much more common when
cutaneous disease (20% of an autopsy...
Primary Cardiac Tumors
• Primary cardiac lymphoma
• Usually involves the RA
• Pericardial involvement is common but not ex...
More Labs and imaging
• LDH: 5640!! uric acid = 11.2
• CT C/A/P: Large ill-defined mass in the LUQ
causing mass effect on ...
• FNA of RP mass: High grade B-cell lymphoma c/w
Burkitt’s Lymphoma
• Started on hydration, alkalinazation, and allopurino...
F/U Echo
F/U Echo
Ready for a quickie?
JP
• 26yo with no PMHx presented to UCSD’s ED 5/13
with h/o cough and dyspnea since Sept
• Intermittent fevers
• Seen in u...
JP
JP
JP
63
Questions
Thank you!
HIV Clinical Cases
HIV Clinical Cases
HIV Clinical Cases
HIV Clinical Cases
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HIV Clinical Cases

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Gigi Blanchard, MD, of UC San Diego Owen Clinic presents "Clinical Cases"

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Transcript of "HIV Clinical Cases"

  1. 1. The UC San Diego AntiViral Research Center sponsors weekly presentations by infectious disease clinicians, physicians and researchers. The goal of these presentations is to provide the most current research, clinical practices and trends in HIV, HBV, HCV, TB and other infectious diseases of global significance. The slides from the AIDS Clinical Rounds presentation that you are about to view are intended for the educational purposes of our audience. They may not be used for other purposes without the presenter’s express permission. AIDS CLINICAL ROUNDS
  2. 2. Cases Gigi Blanchard, MD July 19,2013
  3. 3. DK • DK is a 36yo Indian woman with newly diagnosed HIV who presented w/ fever and progressively worsening back pain • Tested HIV negative in India 2010 prior to her immigration here • Late spring of 2012 developed fevers and anorexia and was diagnosed with HIV by her PCP • Initial CD4 = 162 (7%); VL = 412,652
  4. 4. Chest imaging 7/12
  5. 5. 7/12 Admission for pna • Ruled out for TB with 3 negative AFB smear/cx • Cryptococcal Ag & Histo negative • Cocci CF anti-complementary; ID negative • Bronch wash: • AFB smear and cx negative; MTD - • Silver stain negative • Aspergillus Galactomannan neg • CSF remarkable for WBC = 50, 94% L • Defervesced on ceftriaxone
  6. 6. 7/12 Admission w/ anaphylaxis • Another admission for fever (104.6) and cough • This admission complicated by anaphylaxis • Infectious w/u repeated and still negative • Fever and cough treated with 10 days of IV vanc/aztreonam • Starts RIL/TDF/3TC + RAL
  7. 7. Outpatient F/U • CD4 = 264 – up from 172 • HIV VL = 207 – down from 400K • CT chest 8/12: • Partial resolution of diffuse B/L GGO and centrilobular nodules compatible with resolving infection • Decrease in mediastinal and axillary lymphadenopathy • ABD CT: Stable to decreased retroperitoneal lymphadenopathy
  8. 8. 8/12 Admission • Daily fever (102.6), back and leg pain • No weakness but pain is so bad can’t walk and now has a rash to oxycodone • ROS is o/w negative • MEDS: • RIL/TDF/FTC + RAL • Lorazepam • Zolpidem • Oxycodone
  9. 9. • ALL: • Augmentin • Ceftriaxone • Cipro • Doxycycline • Fluconazole • SMP/TMZ • Azithromycin • Morphine • Micafungin • Shx: • No tob • No etoh • No drugs • Not sexually active • Fhx: • Dad has DM • Aunt with breast cancer
  10. 10. T 102.5 P 104 BP 118/76 RR 16 • GEN: tearful but in no other distress • HEENT: OP clear; no icterus • PULM: CTA B/L • CV: Tachycardic, no M • ABD: soft, NT, ND, NABS; no HSM • BACK/EXT: No spinal tenderness; tender over L SI joint; no edema • NEURO: Moving all extremities; DTRs WNL
  11. 11. • Na 131, K 3.9, Cl 99, Bicarb 19, BUN/Cr nl • AST/ALT: 44/45, ALB 3.8 • WBC = 8.9, H/H = 9.9/30; Plt = 384 • S 36 L 51 E 6 • Sed rate = 99; CRP 6.2 • CD4 = 264; VL = 207
  12. 12. MRI Lumbar Spine
  13. 13. 8/12 Admission • IR unable to aspirate the SI joint but did do a wash- out • WBC 90 (44% PMNs, 44% Lymphocytes, 4% Eos, 8% maacrophages) • Aerobic Culture: Negative • Anaerobic Culture: Negative • AFB Culture: Negative
  14. 14. Admission Sacroiliitis • Brucella Ab <1:20 • Bartonella Ab < 1:64 • Strongyloides Ab 0.03 negative • Lyme 0.26 negative • Coxiella burnetti Ab negative • Cryptococcal Ag negative
  15. 15. 8/12 Admission • 8/13/12 Cocci CF Anticomplementary; ID negative • Numerous bacterial, AFB and fungal cx negative from blood, CSF • Quantiferon negative • TEE negative
  16. 16. A New Result • 8/18/13 Cocci CF + 1:16 • Total body bone scan negative • CSF studies are normal/negative • Desensitized to fluconazole and started on 400mg bid
  17. 17. 18 Case DK July 3-5 July 20 Aug 13 Aug 18 Aug 24 Cryptococcal antigen (serum) Negative Negative Negative Histoplasma antigen (urine) <2.0 (neg) <2.0 (neg) <2.0 (neg) Coccidioides immunodiffusio n (ID) Negative Negative Negative Negative Coccidioides complement fixation (CF) Anti- complementar y Anti- complementar y Positive 1:16 Positive 1:16
  18. 18. Coccidioides
  19. 19. Coccidioidies: forms
  20. 20. • Endemic to arid SW • Arizona, California, Nevada, New Mexico & Utah • Parts of Central and South America
  21. 21. Clinical Manifestations • 50-70% of infections are asymptomatic or so mild that they don’t come to medical attention • Usually self-limited • Complications manifest weeks to 2 years later • The severity of the initial infection does not correlate with the likelihood of complications • Highly infectious (transferring planes in Phoenix) • 1 arthroconidium is enough
  22. 22. Clinical Manifestations • Early respiratory infection • Sx develop 7-21 days after exposure • Onset is usually subacute but can be abrupt • 70-75% have fever and cough • 30-40% have chest pain (pleurisy), dyspnea and fatigue • Weight loss is common • HA occur ~ 20% of the time • Rash: fine papular rash, e nodusum, e multiforme • Migratory arthralgias are common
  23. 23. Pulmonary Findings • Unilateral infiltrates, hilar adenopathy & effusions • Nodules – Peripheral & Solitary • Cavities ~ 8% of the time • Usually thin walled • May develop a mycetoma • Diffuse pulmonary (reticulonodular) infiltrates more common in HIV • May mimic septic shock • Chronic Fibrocavitary Pneumonia
  24. 24. ExtraPulmonary Dissemination • Only 0.5% in general population • Much more common in immunosuppressed • AIDS (CD4 < 100) • Transplant pts • Pts on chronic steroids (prednisone 20mg) • Hodgkin’s lymphoma • More common in men than women (unless she’s pregnant)
  25. 25. ExtraPulmonary Dissemination • Skin: maculopapular lesions to ulcers to abscesses • Joints and bones – any joint can be involved • Synovitis and effusion • Knee; hands and wrists; feet and ankles and the pelvis • Infection may erode to involve bone as well • Vertebral infection is not uncommon with multiple vertebrae involved & may see paraspinous abscesses • Meningitis (eosinophilia in CSF in add’n to usual abnormalities)
  26. 26. Diagnosis • Delayed-type hypersensitivity testing • + for life • Anergy: May be negative during active infection • Direct Examination and culture • Serology
  27. 27. Diagnosis: Direct exam/cx • Identifying spherules in a specimen • Sputum is not infectious • Can’t be detected by Gram Stain • Cytology stains; H&E, silver or PAS stains all work • Grows well on most fungal or bacteriologic media w/in 1 week - • NOTIFY THE LAB - this culture is highly infectious
  28. 28. Serologic Diagnosis • + Antibodies in serum, CSF or other fluid • Highly specific • Even minimally reactive results are significant • A negative test NEVER excludes infection • Repeat tests over 2 months to increase sensitivity • Titer >1:16 ass’d with dissemination • Does not cross react with Cryptococcus or Blasto and very rarely with Histo
  29. 29. Immunodiffusion • Antigen is incorporated into the gel or agar • Serum (antibody) is added to wells, which then diffuses through the Antigen containing gel • Precipitate/ring forms • IgM
  30. 30. 32 Complement Fixation Disease No disease Control (no test antigen) Notes Control (no test antigen) Heat (remove native complement) Add test antigen (coccidioidin) Add standardized complement Incubation Add sensitized sheep RBCs coated with hemolysins Reaction (RBC plug vs Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y OK Anticomplementary
  31. 31. Back to DK • She remains afebrile • Back pain due to anterolisthesis remains severe • Re-admitted 10/12 for out of control pain • Repeat MRI:
  32. 32. • A diagnostic procedure is performed
  33. 33. Non-Hodgkin’s Lymphoma!!
  34. 34. Terry • Terry is a 41yo AA M-to-F with a CD4 = 196 (12%) , VL = 167 in 6/11 who presented to UCSD’s ED 10/12 with several complaints • Had been out of care since 6/11 d/t meth abuse • + dysphagia for solids x 10days; no odynophagia • Abd pain • Chest pain – in the ED, ass’d with EKG abnormalities
  35. 35. Terry • Abd pain – epigastric x 1 week • + N/V; No D or constipation • Not ass’d with eating; no radiation • Wakes her up at night • Chest Pain in the ED • Substernal, stabbing; No radiation • No palpitations; no DOE; no syncope; no orthopnea • Smoked meth on the day of admission • Resolved with ASA and nitro
  36. 36. Terry • ROS: • + anorexia with ~ 20lbs weight loss over 2 mo • F x 2 weeks – as high as 110!; NS x 2 week • No HA; No visual problems; no oral lesions/pain • No easy bruising; epistaxis or bleeding gums • + dry cough; no pleurisy • No pedal edema; no DOE; No orthopnea • No rash
  37. 37. Terry • PMHx • HIV, dx’d in ‘03 • Syphilis • Meds: None • ALL: NKDA • Shx: • on disability • No tob, etoh • Smoked meth 2 weeks ago and on the day of admission • Fhx: mother has DM; Dad A&W
  38. 38. T 97 P119 BP 106/70 RR 22 100% • GEN: thin AAM in NAD • HEENT: poor dentition but no thrush or lesion • PULM: CTA B/L • CV: tachy, but no M/R/G • ABD: soft, NT, ND, NABS; no HSM • EXT: no edema • LN: no cervical, axillary, inguinal LAD
  39. 39. Labs • Na = 131, BUN/Cr = 22/0.17 • Cl = 89, Bicarb = 17 • SGOT/SGPT = 53/17; albumin = 2.6 • AG = 27.5; Lactate = 91.1 • Lipase = 16 • CPK-MB = 9.2 (nl <4.8); • Troponin T = 0.53 (nl < 0.01; >0.09 = MI)
  40. 40. Labs • WBC = 6.8; H/H = 10.9/33.4; Plt = 232 • MCV = 76.1, RDW = 20.9 • S 77; B 3; L 10 • UA: 1.027, 1+ protein; no glu; moderate ketones; 3- 5 WBC; 6-10 RBC; many squames • U tox = + amphetamine; BAL < 9 • Blood cx – pending
  41. 41. Bedside Echo
  42. 42. Cardiac Masses • Infections/endocarditis • Bacteria • Mycobacteria • Fungi • Candida • Aspergillus (intracardiac masses have been described) • Cryptococcus
  43. 43. Cardiac Masses • Thrombi (cluster of grapes; trapped in the chords) • Structural Abnormalities • False tendons (ventricular muscle band that goes from muscle to muscle rather than muscle to valve and it spans the chamber) • Moderator bands (carry the R bundle branch in the RV) • Ruptured chordae tendinae
  44. 44. Cardiac Tumors • Sx depend on size and location • Chest pain, syncope, heart failure • Arrhythmias, murmurs, pleural effusions • Metastatic disease more common than primary tumors • Melanoma, lymphoma most common by incidence • Lung and breast most common by number • Usually nodules or pericardial involvement; chamber involvement less common
  45. 45. Primary Cardiac Tumors • Myxoma • Most common benign tumor • 1/3 of all primary cardiac tumors • 75% involve the LA at the fossa ovalis • 15% involve the RA • Usually solitary unless part of a syndrome • Occur typically in the 3rd to 6th decades • Women > men • Sx are those of obstruction, emboli or constitutional sx
  46. 46. Primary Cardiac Tumors • Sarcoma • Most common malignant primary cardiac tumor • ~ 40% are angiosarcomas • Usually in the RA • Well defined mass • Sx: R sided heart failure or tamponade d/t frequent pericardial involvement • Bloody pericardial fluid usually has no malignant cells • Undifferentiated, rhabdomyosarcoma (arises from valves), osteosarcoma and leiomyosarcoma
  47. 47. Primary Cardiac Tumors • Kaposi’s Sarcoma • Cardiac involvement much more common when cutaneous disease (20% of an autopsy series) • Similar to cutaneous disease, see violaceous plaques and nodules • Usually multiple sites: • Pericardium, epicardium, subepicardium & myocardium • Usually asymptomatic and only found at autopsy
  48. 48. Primary Cardiac Tumors • Primary cardiac lymphoma • Usually involves the RA • Pericardial involvement is common but not extension into the valves • Metastatic (secondary cardiac lymphoma) • Typically aggressive B-cell lymphomas • Present anywhere in the heart • Pericardial, epicardial or diffusely infiltrative • Sx: dyspnea, CHF, CP, epigastric pain • Tamponade, arrhythmia • MI simulated by diffuse myocardial infiltration
  49. 49. More Labs and imaging • LDH: 5640!! uric acid = 11.2 • CT C/A/P: Large ill-defined mass in the LUQ causing mass effect on multiple structures w/o definitive evidence of invasion. The left kidney is displaced inferiorly and the spleen superiorly. • There is mass effect on the splenic vein and artery and the L renal vein and artery w/o evidence of invasion.
  50. 50. • FNA of RP mass: High grade B-cell lymphoma c/w Burkitt’s Lymphoma • Started on hydration, alkalinazation, and allopurinol • R-EPOCH
  51. 51. F/U Echo
  52. 52. F/U Echo
  53. 53. Ready for a quickie?
  54. 54. JP • 26yo with no PMHx presented to UCSD’s ED 5/13 with h/o cough and dyspnea since Sept • Intermittent fevers • Seen in urgent care 10days ago and given course of doxycycline • ROS + for 20lb weight loss
  55. 55. JP
  56. 56. JP
  57. 57. JP
  58. 58. 63 Questions
  59. 59. Thank you!
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