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Grand Rounds

Grand Rounds. Presentor: Mabel Aloc, M.D. March 01, 2007 Ledesma Hall. Objectives. To present a case of HIV / AIDS with multiple opportunistic infections To discuss the diagnosis and management of some of the major complications of HIV / AIDS. General Data. R.D. 24 years old Female

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Grand Rounds

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  1. Grand Rounds Presentor: Mabel Aloc, M.D. March 01, 2007 Ledesma Hall

  2. Objectives • To present a case of HIV / AIDS with multiple opportunistic infections • To discuss the diagnosis and management of some of the major complications of HIV / AIDS

  3. General Data R.D. 24 years old Female Married Ukrainian Lawyer

  4. Chief Complaint word-finding difficulty

  5. History of Present Illness 2 weeks PTA  word-finding difficulty / headache 4 days PTA  upward rolling of eyeballs and stiffening of extremities. Consult was sought. Oxcarbazepine was prescribed. Cranial MRI was done. There was no associated fever, nausea, vomiting, dizziness.

  6. Cranial MRI

  7. + weight loss + anorexia (-) rash (-) heat or cold intolerance (-) polyuria (-) polydipsia (-) dyspnea (-) cough (-) chest pain (-) palpitations (-) orthopnea (-) tendency to bleed or bruise easily (-) dysphagia (-) constipation (-) diarrhea (-) dysuria (-) nocturia Review of Systems

  8. Past Medical History • June 2006  admitted due to dyspnea dx: Pneumocystis carinii pneumonia  HIV positive CD4 count 2.3% CD4/CD8 ratio 0.02 treated with TMP/SMX

  9. Family History (-) Asthma (-) Diabetes Mellitus (-) Hypertension (-) Cancer (-) HIV / AIDS

  10. Personal / Social History • monogamous • denies drug abuse • divorced first husband due to alleged battery / physical assault ? • No history of blood transfusions

  11. Physical Examination General24-year-old caucasian female, drowsy, not in cardiorespiratory distress, with difficulty in self-expression, makes eye contact BP 90/60mmHg HR 88bpm RR 18cpm T 36.9C Weight 45kg Height 5’ 7” BMI 15.5 Skindry skin, no lesions or tenderness; nailbeds pink without clubbing; brisk capillary refill, + tattoo on lateral aspect of left ankle

  12. HEENT scalp without lesions or tenderness conjunctivae pink without discharge pupils react equally to light and accommodation extraocular movements intact red reflex present discs cream colored with well-defined border bilaterally A-V ratio 2:3 cornea, lens, and vitreous clear retina pink, no hemorrhages or exudates macula yellow visual acuity 20/25 no ear / nose discharge buccal mucosa pink and moist

  13. Necktrachea midline, freely movable, thyroid not palpable; lymph nodes nonpalpable Chest and Lungssymmetric chest expansion, tactile fremitus symmetric, resonant percussion throughout, no crackles, no wheezes

  14. HeartApex beat and PMI at 5th intercostal space, LMCL; S1 heard best at apex, S2 heard best at base, no murmurs; regular rhythm Blood Vesselsno neck vein engorgement; no bruits Abdomenfull, soft, nontender; liver, spleen, and kidney not palpable

  15. Lymphaticno palpable lymph nodes in neck, supraclavicular, axillary, epitrochlear, or inguinal areas Musculoskeletalmuscles appear symmetric with appropriate and equal strength bilaterally, full range of active and passive motion

  16. Mental Status Exam conscious, coherent, good attention impaired verbal fluency Intact word comprehension impaired repetition Impaired naming Impaired reading comprehension Impaired writing Neurologic Exam

  17. I - intact sense of smell; II - no visual field cuts, no papilledema II, III - pupils isocoric at 3mm EBRTL III, IV, VI - full EOM V - intact facial sensation, strong muscles of mastication VII - Right central facial palsy VIII - Weber’s test is midline, Rinne’s test – AC > BC, AU IX, X - + gag reflex, uvula at midline XI - able to shrug shoulders and turn head against resistance XII - tongue at midline, no atrophy noted Cranial Nerve Examination

  18. Motor Examination individual muscle groups are graded 5/5 on all extremities Sensory Examination intact to pain, temperature, light touch, vibration and position sense, (-) Romberg’s test Deep Tendon Reflex +2 on all extremities

  19. Cerebellar Tests able to do finger to nose test, able to do rapid alternating pronation / supination of the hands, no nystagmus Meningeal Tests supple neck, (-) Kernig’s sign, (-) Brudzinski sign Pathologic Reflexes (-) Babinski sign, (-) Grasp reflex Gait Exam able to walk on heels, toes, and tandem walk well

  20. 24y/o female causasian Expressive aphasia, headache MRI: T/C cerebral infection Hx: Pneumocystis carinii pneumonia, HIV positive BMI 15.5 Impaired verbal fluency, repetition, naming, reading comprehension, and writing Right central facial palsy Salient Features

  21. Initial Impression Acquired Immune Deficiency Syndrome CNS Infection, r/o Parasitic Disease with Abscess Formation

  22. Course in the Wards On admission  mannitol, citicholine, oxcarbazepine started  Infectious Disease referral: started Pyrimethamine- Sulfadoxine (Fansidar) and Clindamycin, and Folinic acid

  23. 2nd H.D.  Referral to Gastroenterology service due to elevated liver transaminases  Fansidar and Clindamycin shifted to Trimethoprim/Sulfamethoxazole  UTZ: no hepatobiliary abnormalities  Anti HCV reactive  HCV RNA > 850,000 iu/mm  started nutritional and liver support

  24. 7th H.D.  Referral to Ophthalmology service due to blurring of vision. Fluorescein angiography was done and CMV retinitis was diagnosed. CMV antigenemia 13- 15wbc/smear  Valganciclovir started

  25. Fluorescein Angiography

  26. Fluorescein Angiography

  27. 8th H.D.  increasing aphasia  TMP/SMX shifted to Fansidar and Azithromycin  Toxoplasma IgG: negative

  28. Stereotactic Brain Biopsy

  29. Final Histopathologic Report: Inflammatory process with necrosis. No definite Toxoplasmacyst identified. No malignant cells.

  30. Acid fast, silver, and PAS stains were negative. Aerobic culture of brain tissue was negative and mycobacterial culture remained negative by the first week of incubation. Repeat Toxoplasma IgG was negative.

  31. 9th H.D.  developed oral thrush  Nystatin started Antiretroviral therapy and tests for CD4 count and HIV viral load were deferred until the acute opportunistic infections stabilized. The patient was discharged on the 14th H.D. alert, headache-free, without seizure recurrence but with persistent expressive aphasia.

  32. Final Diagnosis Acquired Immune Deficiency Syndrome CNS lesion, probable Toxoplasma Encephalitis CMV Retinitis Hepatitis C Oral Candidiasis Pneumocystis carinii Pneumonia, Resolved

  33. Acquired Immune Deficiency Syndrome

  34. History • First recognized in mid-1981  clusters of Pneumocystis carinii pneumonia and Kaposi’s sarcoma reported in young, previously healthy homosexual men in New York City, Los Angeles, and San Francisco • Subsequent documentation of cases among persons with hemophilia, blood transfusion recipients, and heterosexual injecting drug users and their sex partners

  35. 1983  cytopathic retrovirus isolated • 1985  serologic tests to detect evidence of infection with HIV had been developed and licensed

  36. Natural History of HIV Infection

  37. Antiretroviral Therapy

  38. Indications for Initiating ART for Chronic HIV Patients

  39. Testing for Plasma HIV RNA Levels and CD4+ T Cell Count to Guide Decisions Regarding Therapy

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