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AIDS CLINICAL ROUNDS

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

• 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

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-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

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

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

8/12 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

• 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

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

• 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

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% maacrophages)

• Aerobic Culture: Negative

• Anaerobic Culture: Negative

• AFB Culture: Negative

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

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

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

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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

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 • 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

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

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

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)

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)

Diagnosis

• Delayed-type hypersensitivity testing • + for life

• Anergy: May be negative during active infection

• Direct Examination and culture

• Serology

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

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

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

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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

Back to DK

• She remains afebrile

• Back pain due to anterolisthesis remains severe

• Re-admitted 10/12 for out of control pain

• Repeat MRI:

• 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 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

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

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

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

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

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)

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

Bedside Echo

Cardiac Masses

• Infections/endocarditis • Bacteria

• Mycobacteria

• Fungi • Candida

• Aspergillus (intracardiac masses have been described)

• Cryptococcus

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

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

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

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

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

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

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.

• FNA of RP mass: High grade B-cell lymphoma c/w Burkitt’s Lymphoma

• Started on hydration, alkalinazation, and allopurinol

• R-EPOCH

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 urgent care 10days ago and given course of doxycycline

• ROS + for 20lb weight loss

JP

JP

JP

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Questions

Thank you!