12/8/18 I have no disclosures. Interesting Cases in HIV Medicine Elizabeth Imbert, MD MPH Assistant Professor Division of HIV, ID, and Global Medicine Zuckerberg San Francisco General UCSF Case 1 • 46 homelessness man who has sex with men and women and uses IV • On exam, V/S 125/76 P 127 T 37.7 RR 12 O2 sat 97% on RA. Exam notable for thrush and erythematous edematous area overlying R sternoclavicular meth, who was recently diagnosed at an outside hospital with HIV joint with tenderness to palpation. after presenting with months of fever/sweats/weight loss. He was not • CBC: 4.4<8.2>329 started on ARVS and now presents to urgent care with continued constitutional symptoms as well as neck and chest pain. • CMP: WNL • LDH: 205 • CRP 66.5 • ESR: 132 • CD4: 81 • VL: 848K
12/8/18 Additional work-up • CT neck showed R • His blood cx from outside hospital grew Staph schleiferi in 2/2. sternoclavicular osteolysis and • Repeat blood cx were NGTD. soft tissue enhancement • LP WBC 0, glucose 47, protein 27 • His MRI spine showed cervical • TTE was negative. discitis-osteomyelitis of C4/C5 with prevertebral fluid collection • An attempt to aspirate his SC joint did not return fluid. and phlegmonous changes at T10/T11. (insert photo->) Staph schleiferi bacteremia • He was empirically given 6 weeks of vancomycin/ertapenem to treat osteomyelitis and presumptive endocarditis.
12/8/18 What is the most likely diagnosis? • His Chest CT scan showed multiple pulmonary nodules. • PCP • On further history, he denied any cough or shortness of breath. • Bacterial pneumonia • Insert picture • TB • Fungal pneumonia • Pulmonary Kaposi sarcoma • Non-Hodgkin lymphoma • Cytomegalovirus He subsequently underwent bronchoscopy • Patient shares with the team that he has a bump on the top of his mouth.
12/8/18 Work-up Palate lesion biopsy • Cocci Ab IF negative; Cocci Ab CF neg • Expectorated sputum • Insert picture • MTB complex target DNA neg x 2 • CrAg neg • AFB neg x 2 • Blood • Induced sputum • Fungal cx NGTD • AFB neg • AFB blood cx NGTD • CSF • BAL • No fungus recovered • CMV and HSV recovered from cx • No AFB recovered • Neg for PJP • Urine histoplasma Ag negative • Candida Albicans • Candida Glabrata • BDG 259 • + MAC • No AFB on cx Kaposi Sarcoma Follow-up • He was started on TAF/FTC/DTG and TMP-SMX for prophylaxis for PJP and at 1 year from presentation, his VL is UD and CD4 now 129. • He was given doxil for his KS and on repeat chest CT he has continued nodules that are reduced in size.
12/8/18 Final diagnosis Case 2 • Staph schlefieri bacteremia; osteomyelitis of cervical and thoracic • 57 M with HIV VL 47 CD4 313 on ARV who has sex with men and a spine and presumed sternoclavicular septic joint; and pulmonary and history of using IV methamphetamine presenting to urgent care with palate Kaposi sarcoma 1 week of R hand pain, swelling and redness that started after he noted a blister on his hand and b/l shoulder pain. He also reports a pruritic rash on his chest 1 week prior to his hand pain. Denies trauma/fever/chills/sweats. +malaise/myalgias. • In urgent care found to be BP 121/82 P 115 RR 18 T 37 O2 Sat 98% • On exam, had a erythematous/warmth/edema of R hand and limited ROM of b/l shoulders 2/2 pain and pain on palpation of deltoids. • X-ray with right 5 th metacarpal fx. • Unclear why patient had fracture as reported no inciting event. • ESR 92. CRP H. Blood cx NGTD; Wrist fluid cx NGTD. • Overlying redness/swelling thought to be cellulitis and treated with vancomycin initially and then switched to bactrim. • Underwent arthocentesis by orthopedics and admitted to the hospital. • He was subsequently noted by team to have worsening strength in b/l deltoids. • CK was normal and an MRI of his cervical spine showed chronic DJD. • Proximal pain and weakness of his upper extremities in setting of elevated ESR thought to be polmyalgia rheumatica and started on prednisone.
12/8/18 3.5 weeks later… Work-up • Patient woke up with excruciating pain in R wrist and presented to the • Throat cx: +GC emergency room. Also c/o L shoulder, L sternoclavicular and R knee • Fluid wrist cx ngtd arthlagias. • Blood cx ngtd • On exam, V/S BP 103/70 P 127 T 35.8 RR 20 O2 Sat 98% RA; R wrist swollen, tender to palpation with ROM limited by pain; he has pain with • Bone R wrist cx: Enterobacter cloacae. N gonnorrhea movement of b/l shoulders and R knee effusion, without erythema/warmth. • Synovial fluid R wrist cx: N gonnorrhea • Repeat X-ray of wrist revealed new bony erosions (insert picture). • He was brought to the OR where he underwent arthrotomy. There was no purulence, but he was noted to have unhealthy synovium and the carpal tunnel bones appeared soft. Synovial cx and bone cx were sent. Follow-up • Prednisone was rapidly tapered • Patient was started on IV ceftriaxone x 6 weeks and gonorrohea was sent for antibiotic sensitivities.
12/8/18 Final diagnosis Case 3 • Disseminated Gonococcal disease with Gonococcal Osteomyelitis • 47 M with HIV CD4 215 VL UD on ARV presenting with pruritic morbilliform rash and dental abscess and found to have new pancytopenia. • Blood cx subsequently return with one out of 2 MSSA, CoNS, and Micrococcus luteus. • In work up, also got CT chest/abdomen pelvis: CT chest with GGOs and CT abdomen with splenomegaly and diffuse LAD. • Polymicrobial nature of blood cx thought to be unclear per ID and plan to treat via PICC line with cefazolin for MSSA as thought to be true pathogen and likely 2/2 SSTI. 2 weeks later, patient returns to urgent care… • Upon discharge from the hospital, PCP arranges outpatient FNA of • c/o fevers, malaise and non-productive cough x weeks and 1-2 loose inguinal LAD which shows reactive changes. stools per day. • V/S T 38.7, P 127, BP 115/70, O2 sat 98% RA. • He is admitted to medicine and blood cx from PICC return MSSA and stool cx returns + for C diff. • Despite PO vancomycin and IV vancomycin, he remains persistently febrile.
12/8/18 He undergoes FNA of L inguinal LN… FNA reveals… • HHV-8 + multicentric Castelman’s disease Final diagnosis • Multicentric Castleman’s disease
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