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Most Memorable Cases Dr Getachew Feleke January 14, 2010

Most Memorable Cases Dr Getachew Feleke January 14, 2010. Objectives. Highlight common and less common infectious complications of HIV/AIDS. Generate discussion on factors that can impact the outcomes of these infections. Generate discussion on when to start HAART in the face of acute OIs.

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Most Memorable Cases Dr Getachew Feleke January 14, 2010

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  1. Most Memorable Cases Dr Getachew Feleke January 14, 2010

  2. Objectives • Highlight common and less common infectious complications of HIV/AIDS. • Generate discussion on factors that can impact the outcomes of these infections. • Generate discussion on when to start HAART in the face of acute OIs.

  3. Case I & II Case I • 42 years old Female presented with cough, purulent sputum, respiratory distress and fever of 2 weeks duration • T=1030 F, RR=32 /min, chest- rales and basal dullness Case II • 28 years old Female with similar history, had completed treatment for TB; sputum was blood tinged • T=1010F, RR=28, chest-rales • Both were HIV+

  4. Follow up Case I Case II • CXR bil. infiltrates/opacities Similar • CD4 8/mm3 12/mm3 • When 1994 2008 • Where NY Ethiopia What is the likely diagnosis? Prognosis?

  5. Continued… Case I Case II Sputum AFB smear -ve 3X -ve 3X Blood culture -ve not av. Cryptococcal Ag not reactive not av. BAL No PCP not av. O2 Saturation 60% not av. CT of chest Bil. infiltrates not av. effusion/ empyema

  6. How do you manage these patients? Case I Case II Hosp. admission Yes No Antibiotic IV; broad Spec. Amox.(PO) TMP/SMX Yes (IV) Yes (PO) Pleural Tap Yes Not done Supportive Care Aggressive Minimal

  7. Diagnosis: Severe bacterial pneumonia; Empyema Case I Case II • Outcome alive with CD4 Expired in 2weeks 600+ in 2008 What modifiable factors might have contributed to the difference in outcome? • Supportive care- oxygen, chest tube, close monitoring • Knowledge and skill gap? • Attitude of the HW or client? • Availability of services( diagnostic, therapeutic) and skilled manpower • Up to 25% of cases may not have identifiable bacteria but respond to antibiotics

  8. Infectious etiology in HIV(bacterial/fungal)

  9. Bacterial Infections in HIV/AIDS • Bacterial pneumonia is a major cause of morbidity and mortality in HIV/AIDS • Choice of empiric therapy should target potential causative agents • Severe pneumonia if recognized early is treatable

  10. Case III HI: 39 years old male diagnosed with HIV a month ago presented with weight loss (10 kg in 2 months) weakness and diarrhea of 3 weeks duration

  11. Continued….. • PMH: Cough, hemoptysis and fever 6 weeks ago and improved with Amoxicillin • P/E :Sick looking, cachectic, multiple papular skin lesions on the face; dry scaly skin. • Lab: CD4= 7/mm3 : VL= 392,627c/ml :Tuberculin skin test-no induration.

  12. Radiologic Finding Chest x-ray CT chest

  13. Biopsy Finding“Malakoplakia” Michael’s Guttmann bodies Foamy macrophages

  14. Culture Result • Gram variable Coccobacilli • Weakly Acid Fast Identification: Rhodoccous equi Management • Antibiotic: Clarithromycin, Vancomycin • HAART: Combivir/Kaletra • Prophylaxis: TMP/SMX, Azithtromycin • Patient fully recovered; CD4 =400 in 2008

  15. R.equi Pneumonia in AIDS • Presentation is sub acute with productive cough & occasional hemoptysis • CXR: infiltrates, nodules, cavities, abscess, empyema • CD4 < 100;bacteremia is common • Treatment: two antibiotics for > 6 wks; generally resistant to Penicillin/Cephalosporin • Prognosis in the era of HAART is good.

  16. Case IV • 37 years old Hispanic male from central America presented with fever, headache and weight loss of two weeks duration. • P/E: cachetic, sick looking, T=1010F • Umblicated papular lesions on face.

  17. Continued…. Lab • Hgb= 8.6, WBC=10.4 diff. 69% N & 18% L • CD4=8/mm3 • VL=750,000 c/ml. • CXR=NAD • CT of head-No abnormality Clinical Decision

  18. Follow Up • Blood culture- negative • CSF: India ink-positive : WBC =18/mm3 with 83% L; 9% N : OP = 250 mmH2o • Crypt Ag=1:1024 • Ampho. B 0.7mg/kg/d + Flucytosine • Started on Kaletra, AZT+3TC, Azithromycin • Improved and discharged on Fluconazole 600mg PO daily.

  19. Follow Up continued.. • 7 wks later he presented with fever, dizziness, cough and vomiting after being found unconscious in the bath room. • T= 101oF, bil. basal rales, CNS :a & o, non focal. • WBC=20,500/mm3 with 80%N;13%Bands • CXR=bilateral infiltrates; LML cavity • CT head- cerebral edema, no mass, no herniation. Clinical Decision

  20. Case IV follow up • Admitted to ICU, started on Pipercillin-Tazobactam,Vancomycin, Amphotericin B, IV Fluconazole, Dexamethasone • LP done: OP= 400 mmH2o, India Ink was positive, Lumbar drain & intra thecal Amphotericin B. • Patient deteriorated and died after 3 weeks of hospitalization. Clinical Discussion • What is the cause of death? • Overwhelming Cryptococcal meningitis?, • Bacterial super infection? Aspiration pneumonia? • IRIS?, (?paradoxical;?unmasking)

  21. Autopsy Findings Lung Lung GMS stain Mucicarmine stain

  22. Case IV-Autopsy Diagnosis • Acute necrotizing Bronchopneumonia • Left lower lung cavity- Cryptococcal abscess • Necrotizing granuloma with numerous budding yeast in para tracheal mass • Budding yeast in spinal cord • Blood culture= Pseudomonas (post mortem)

  23. Cryptococcosis:A major cause of morbidity in AIDS Cryptococcal Disease Global Burden(Park et al IDSA 2008) Prognostic factors in Cryptococcal Meningitis

  24. Early Vs Delayed HAART in the setting of Acute OIs • 282 subjects; PCP 63%; Crypt. 12%, bacterial infection 12 %. Early HAART had fewer AIDS progression/ death, OR=0.51, CI (0.27-0.94). No difference in safety, toxicity, IRIS at week 48.1 • 54 Crypt. meningitis cases treated with Fluconazole, early HAART ( with in 72 hrs) had greater mortality (82%) Vs delayed HAART (10 weeks), 32 % overall mortality 62 %.2 1.https://www.plosone.org/article/info:doi/10.1371/journal.pome.005575, 2.makadzange (CROI 2008, late breaker

  25. Cause specific mortality and contribution of IRIS in Urban cohort Method: Determination of cause specific mortality and role of IRIS over 36 months at the IDI of Makerere University. Result: • 17% (90) died in 36 months • 14 %(80) died with in the 1st year • (13%) 73 patients died with in the 1st three months Causes of death • 69/80 deaths that occurred during the 1st year were AIDS related • Only four were attributed to IRIS Source: Castelnouve CID 2009; 49;965-72

  26. Summary • Progressive decline in CD4 count increases the risk to all infections • Bacterial infections (non TB) are common in HIV/AIDS • Early HAART leads to better outcome • Cryptococcus remains a common cause of mortality • IRIS complicates early management of HIV but may not be enough to delay ART

  27. Next session: January 21, 2010 Listserv: itechdistlearning@u.washington.edu Email: DLinfo@u.washington.edu

  28. Next session: January 21, 2010 Dr Roy Colven HIV Dermatology: Virtual Office Hours

  29. Extra slides

  30. India Ink

  31. “Failure to manage elevated ICP is the most dangerous mistake in management”CID 2005;40:477

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