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MEDICAL GRANDROUNDS: Yeast, I’m Vulnerable!

Maria Regina V. Pelobello, M.D. September 3, 2009. MEDICAL GRANDROUNDS: Yeast, I’m Vulnerable!. Objectives. To present a case of an unusual infection in a a 26-year-old male To discuss the disease course, management and prognosis. General Data. R.P., 26M Single call center agent

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MEDICAL GRANDROUNDS: Yeast, I’m Vulnerable!

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  1. Maria Regina V. Pelobello, M.D. September 3, 2009 MEDICAL GRANDROUNDS:Yeast, I’m Vulnerable!

  2. Objectives • To present a case of an unusual infection in a a 26-year-old male • To discuss the disease course, management and prognosis

  3. General Data • R.P., 26M • Single • call center agent • residing in Makati 

  4. Chief Complaint • headache

  5. History of Present Illness 3 ½ weeks PTA • Headache • Gr 1-2/10  10/10, • generalized, throbbing • Paracetamol • Out-px consult: given pain medications

  6. 2 ½ wks PTA • Dizziness, vomiting • Headache • MMC: admitted for 4 days • EEG : abnormal • MRI / MRA of the brain and intracranial vessels : normal • Imp: Mixed Type Headache (Migraine with Tension Headache) • etoricoxib, betahistine, flunarizine, eperisone, diazepam

  7. 6 days PTA • Headache • bitemporal, frontal • throbbing • Gr 5/10 10/10 • 30 minutes to an hour • Occasionally awakened from sleep • Associated with vomiting • Drowsiness • Dizziness, rotatory

  8. 2 days PTA Day of adm • Undocumented fever • blurring of vision • increased drowsiness • several episodes of disorientation • No loss of consciousness, tremors, tonic-clonic movements, slurring of speech

  9. Review of Systems • No weight loss, anorexia, weakness • No skin rashes • No tinnitus • No gum bleeding • No cough, colds • No dysuria • No diarrhea

  10. Past Medical History • No hypertension, diabetes or asthma • No history of treatment for PTB • No seizure disorder • s/p knee surgery • No previous blood transfusion • No previous steroid therapy • No known allergies

  11. Family History (-) Hypertension (+) Diabetes Mellitus (-) Bronchial Asthma (-) Pulmonary Tuberculosis (-) Seizure disorder

  12. Personal and Social History • Functions independently • 10 sticks per day for the past 3 years • occasional alcoholic beverage drinker • denies use of illicit drugs • No history of recent travel • Multiple sexual partners, same gender preference

  13. Physical Examination • lethargic, not in cardio-respiratory distress • BP 110/80, HR 82, regular, RR 20, T 36 C • Height 61cm, weight 59 kg • Warm moist skin, no active dermatoses • Pink palpebral conjunctivae, anicteric sclerae • Moist buccal mucosa, no oral thrush • Initially with supple neck, no palpable cervical lymphadenopathies

  14. Physical Examination • Symmetrical chest expansion, no retractions, clear breath sounds • Adynamic precordium, AB 5th LICS, MCL , (-) murmurs • Flabby Abdomen, normoactive bowel sounds, soft, non-tender, no hepatosplenomegaly • Extremities no edema, no cyanosis, pulses full and equal

  15. Neurologic Exam • drowsy, oriented 3 spheres, follows commands, • no right-left confusion, no finger agnosia, no apraxia • Cranial nerves intact • Pupils 3mm ERTL, full EOMs, no nystagmus • V1 – V3 intact • No facial asymmetry, tongue and uvula midline • No sensory deficits • MMT 5/5 on all extremities • No dysmetria, dysdiadokinesia. Steady gait.

  16. At the ED (0n re-assessment after 3 hours) Nuchal rigidity, (+) brudzinski unsteady gait (falls to either side)

  17. Salient Features • 26M • CC: headache • Vomiting • Dizziness • blurring of vision • Undocumented fever • Nuchal rigidity

  18. Admitting Impression • Increased intracranial pressure • Consider Meningitis • Bacterial vs Viral vs Fungal

  19. Problem 1: headache, fever, nuchal rigidity, changes in sensorium • Assessment • consider increased intracranial pressure • consider meningitis • Diagnostics • CBC, stat 5, urinalysis • CT scan (plain and contrast): normal • Lumbar puncture

  20. Problem 1: headache, fever, nuchal rigidity, changes in sensorium • Therapeutics • Mannitol 20 % 100ml q4hrs • Dexamethasone 5mg IV q8hrs • Citicoline 1g IV q8hrs • Ceftriaxone 2g IV q12hrs

  21. 1st Hospital Day • Na 134 • K 3.0 • RBS 182 • Hgb 11.2 • Hct 33 • Urinalysis: +2 blood, 1/1/1/23

  22. Lumbar Puncture

  23. 1st HD • Infectious disease referral • Continue ceftriaxone 2g IV q12hrs

  24. Lumbar tap: 1st HD • Ceftriaxone was discontinued • Fluconazole 400 IV q24hrs  • amphotericin B 50mg q24hrs (0.85 mg/kg/day)

  25. C. neoformansin india ink

  26. Lumbar Puncture : 1st HD • Culture • light growth of Cryptococus spp • TB culture • no growth after 6 weeks incubation

  27. Problem 2: immunocompromised state • Assessment • Rule out HIV • Diagnostics • CD 4 = 28 per microliter • Therapeutics (5th HD) • cotrimoxazole 800/160 mg/tab OD • azithromycin 500mg/tab, 2 tabs once a week 

  28. Problem 2: immunocompromised state • 6th Hospital Day • Amphotericin B discontinued • Fluconazole 400mg IV every 24hours • cotrimoxazole 800/160 mg/tab 3x a week • continue antifungal treatment for 2 weeks before starting anti-retroviral therapy • 20th Hospital Day  • lamivudine + zidovudine 1 tab 2x a day • efavirenz 600mg daily

  29. Immune Reconstitution Inflammatory Syndrome • paradoxical worsening of preexisting, untreated, or partially treated opportunistic infections after initiation of ARV • CD4+ T cell counts <50 cells/L who have a precipitous drop in HIV RNA levels following the initiation of HAART • localized lymphadenitis, prolonged fever, pulmonary infiltrates, increased intracranial pressure, uveitis • reflects the immediate improvements in immune function

  30. Problem 3: seizure episodes • 7th HD • Upward rolling of eyeballs, fully awake • Impression: increased intracranial pressure • Diagnostics • Advised repeat CT scan and LP • Therapeutics • Valproic acid 250mg TID • Mannitol

  31. Problem 3: seizure episodes • 11th HD • Recurrent seizure episodes • Patient appears very drowsy and confused • Impression • Increased intracranial pressure • Diagnostic and Therapeutic • Stat Lumbar tap

  32. Lumbar tap: 11th HD • 13th HD • Recurrence of seizures • India ink still positive • Amphotericin resumed

  33. Problem 4: amphotericin-associated renal insufficiency • 16th HD • Serum creatinine (1.6) • amphotericin B was discontinued  • fluconazole 200mg IV every 24 hours • 26th HD • Referral to Nephrology for fluid and electrolyte management

  34. 32rd HD • Patient went into CP arrest, but was revived • 33rd HD • Patient expired

  35. discussion

  36. Definition

  37. Definitions

  38. Category B

  39. Category B

  40. Category C

  41. Category C

  42. Human Immunedeficiency Virus • family of Retroviridae • subfamily lentiviridae • four recognized human retroviruses • human T lymphotropic viruses (HTLV)-I and HTLV-II • human immunodeficiency viruses, HIV-1 and HIV-2 • most common cause of HIV disease throughout the world: HIV-1

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