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CASE 1

CASE 1. 55 yo man…Baker HIV+ since 1996 Refused bloodwork over the years as was ‘Feeling fine’ Oral hairy leukoplakia noted on oral biopsy in 2001. CASE 1. Fall 2013 Dry cough/ soboe …no fevers Seen by respirology …bronchoscopy negative for pathogens. CASE 1. Fall 2013

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CASE 1

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  1. CASE 1 • 55 yo man…Baker • HIV+ since 1996 • Refused bloodwork over the years as was ‘Feeling fine’ • Oral hairy leukoplakia noted on oral biopsy in 2001

  2. CASE 1 Fall 2013 • Dry cough/soboe…no fevers • Seen by respirology…bronchoscopy negative for pathogens

  3. CASE 1 Fall 2013 Was felt to have extrinsic allergic alveolitis….type of ”Bakers lung” Treated with a few months of prednisone with effect

  4. CASE 1 Winter 2014…still on Prednisone • Intractable nausea and vomitting • Admitted and diagnosed with Cryptococcal meningitis • Multiple cutaneous KS lesions

  5. CASE 1 Winter 2014 • Steroids stopped and IV amphotericin instituted with effect…eventually switched to oral Fluconazole

  6. CASE 1 Winter 2014 • At time of Cryptococcal diagnosis…lungs had significant disseminated nodular infiltrates that were felt to represent Cryptococcal disease as part of a disseminated Cryptococcal syndrome • No bronchoscpy done

  7. CASE 1 FEB-MAR 2014 • Discharged from hospital and ready to consider HIV meds but wants to see bloods first • CD4 110/6% HIV viral load 98,422 • Genotype clear

  8. CASE 1 FEB-MAR 2014 • Clinically still coughing without fever or SOBOE • No headache or fever • Multiple cutaneous KS lesions

  9. CASE 1 MAR 2014 • Still refused to start ARVS but clearly more receptive • Wanted to see CD4 off steroids • CD4 90/5% HIV Viral load 389,878

  10. CASE 1 APR 2014 • Initiated TDF/FTC/Raltegravirnow 4 months from initiation of Cryptococcal therapy…refused PCP prophylaxis but continued on Cryptococcal maintenance therapy with Fluconazole

  11. CASE 1 APR 2014 • Cough worsened a few weeks post initiation of ARVS but no fever or flu like symptoms…otherwise improving clinically

  12. CASE 1 MAY 2014 • CT chest reveals worsening coarse nodular infiltrates in chest • New KS lesions now slowing and older lesions beginning to darken

  13. CASE 1 MAY 2014…1 month post initiaton of ARVS • CD4 110/7% HIV viral load 184 • Worsening respiratory symptoms with increasing soboe…unresponsive to antibacterials • Bronchosocpy/BAL/Transbronchial biopsy performed

  14. CASE 1 MAY 2014 • No KS seen in bronchi…BAL negative for pathogens/biopsy revealed chronic inflammation • Admitted to hospital and high dose steroids initiated

  15. CASE 1 MAY 2014 • Worsening symptoms c/w ARDS/IRIS • Transferred to ICU and treated for bacteria/PCP/fungi • Succumbed to respiratory illness

  16. CASE 1 JUNE 2014 TAKE HOME MESSAGE THIS COULD HAVE ALL BEEN AVERTED WITH EARLY INITIATION OF ARVS TRY NOT TO USE STEROIDS IN HIV

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