Interesting Cases in HIV Medicine Elizabeth Imbert, MD MPH - - PDF document

12/8/18

Interesting Cases in HIV Medicine

Elizabeth Imbert, MD MPH Assistant Professor Division of HIV, ID, and Global Medicine Zuckerberg San Francisco General UCSF

I have no disclosures. Case 1

• 46 homelessness man who has sex with men and women and uses IV

meth, who was recently diagnosed at an outside hospital with HIV after presenting with months of fever/sweats/weight loss. He was not started on ARVS and now presents to urgent care with continued constitutional symptoms as well as neck and chest pain.

• 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 joint with tenderness to palpation.

• CBC: 4.4<8.2>329
• CMP: WNL
• LDH: 205
• CRP 66.5
• ESR: 132
• CD4: 81
• VL: 848K

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• CT neck showed R

sternoclavicular osteolysis and soft tissue enhancement

• His MRI spine showed cervical

discitis-osteomyelitis of C4/C5 with prevertebral fluid collection and phlegmonous changes at T10/T11. (insert photo->)

Additional work-up

• His blood cx from outside hospital grew Staph schleiferi in 2/2.
• Repeat blood cx were NGTD.
• LP WBC 0, glucose 47, protein 27
• TTE was negative.
• An attempt to aspirate his SC joint did not return fluid.

Staph schleiferi bacteremia

• He was empirically given 6 weeks of vancomycin/ertapenem to treat
• steomyelitis and presumptive endocarditis.

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• His Chest CT scan showed multiple pulmonary nodules.
• On further history, he denied any cough or shortness of breath.
• Insert picture

What is the most likely diagnosis?

• PCP
• Bacterial pneumonia
• TB
• Fungal pneumonia
• Pulmonary Kaposi sarcoma
• Non-Hodgkin lymphoma
• Cytomegalovirus
• Patient shares with the team that he has a bump on the top of his

mouth.

He subsequently underwent bronchoscopy

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Work-up

• Cocci Ab IF negative; Cocci Ab CF neg
• CrAg neg
• Blood
• Fungal cx NGTD
• AFB blood cx NGTD
• CSF
• No fungus recovered
• No AFB recovered
• Urine histoplasma Ag negative
• BDG 259
• Expectorated sputum
• MTB complex target DNA neg x 2
• AFB neg x 2
• Induced sputum
• AFB neg
• BAL
• CMV and HSV recovered from cx
• Neg for PJP
• Candida Albicans
• Candida Glabrata
• + MAC
• No AFB on cx

Palate lesion biopsy

• Insert picture

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.

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Final diagnosis

• Staph schlefieri bacteremia; osteomyelitis of cervical and thoracic

spine and presumed sternoclavicular septic joint; and pulmonary and palate Kaposi sarcoma

Case 2

• 57 M with HIV VL 47 CD4 313 on ARV who has sex with men and a

history of using IV methamphetamine presenting to urgent care with 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 5th metacarpal fx.
• ESR 92. CRP H. Blood cx NGTD; Wrist fluid cx NGTD.
• Underwent arthocentesis by orthopedics and admitted to the

hospital.

• Unclear why patient had fracture as reported no inciting event.
• Overlying redness/swelling thought to be cellulitis and treated with

vancomycin initially and then switched to bactrim.

• 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.

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3.5 weeks later…

• Patient woke up with excruciating pain in R wrist and presented to the

emergency room. Also c/o L shoulder, L sternoclavicular and R knee arthlagias.

• 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 movement of b/l shoulders and R knee effusion, without erythema/warmth.

• 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.

Work-up

• Throat cx: +GC
• Fluid wrist cx ngtd
• Blood cx ngtd
• Bone R wrist cx: Enterobacter cloacae. N gonnorrhea
• Synovial fluid R wrist cx: N gonnorrhea

Follow-up

• Prednisone was rapidly tapered
• Patient was started on IV ceftriaxone x 6 weeks and gonorrohea was

sent for antibiotic sensitivities.

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Final diagnosis

• Disseminated Gonococcal disease with Gonococcal Osteomyelitis

Case 3

• 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.

• Upon discharge from the hospital, PCP arranges outpatient FNA of

inguinal LAD which shows reactive changes.

2 weeks later, patient returns to urgent care…

• c/o fevers, malaise and non-productive cough x weeks and 1-2 loose

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.

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He undergoes FNA of L inguinal LN… FNA reveals…

• HHV-8 + multicentric Castelman’s disease

Final diagnosis

• Multicentric Castleman’s disease