A Child with Cross Eye. Nia Kurniati

Transcription

1 A Child with Cross Eye Nia Kurniati

2 Background When dealing with new case with potential social problem, complication related to ARV treatment may pose difficulties Restricted resource to address potential problem Common opportunistic infection screening is useful, immune reconstitution inflammation syndrome (IRIS)

3 Case C, a 6 year old girl came to HIV service for diagnosis 2007 C, 2 month old Parents HIV diagnosed February 2013 C was confirmed to be HIV positive March 2013 Started HAART She has 3 siblings (17,13, 6[twin] which are all uninfected)

4 Initial Started to have health problem in the last year (fever, middle ear infection, recurrent URTI) No history of TB contact Body weight 19 kg Body height 115 cm (P 3 P 5 US CDC growth chart) No liver enlargement, no lymph node enlargement Hemoglobin level 10.2 g/dl AST 45 U/L, ALT 23 U/L Cd4 was 101 cells/ul (5%) VL 1.42 Log10 6 ARV: AZT + 3TC + NVP Time elapsed from diagnosis to starting ARV: 3 weeks

5 Week 4 ARV Week 4 in ARV her right eye became cross. There was no other symptoms (systemic or neurologic). Parent thought of adjustment of eyeglass strength

6 Tan, et al. HIV_associated OI of the CNS. The Lancet Neurology 2012;11:605-17

7 Week 5 ARV, 1st week symptom IRIS was taken into consideration (DD/ TORCH and TB) Diagnostic step: eye examination No intraocular abnormalities. Brain CT scan multiple hypodense lesions found in all cerebral and cerebellar parenchyme. Serology for CMV, Toxoplasma and Herpes Virus Lumbal puncture

8 Week 6 ARV, 2nd week symptom While waiting for laboratory results (vary from 1 10 days), patient gradually had fever and liver enlargement, we decide to hospitalize CSF result: lymphocyte predominant (65%), with normal protein and glucose level, and negative AFB smear Started on IV Acyclovir, 4 antituberculous drug and steroid while maintaining ARV

9 Week 6-9 ARV, 2-5 weeks of symptom Her eye became straight Despite therapy, patient started to have generalized seizure and decrease consciousness She was transferred to PICU and received anticonvulsants for 3 weeks IV Gancyclovir was started on 2 week in PICU

10 Lab results Anti toxoplasma IgG 0,1 IU/mL(Non reactive) Anti toxoplasma IgM 0,2 COI (Non reactive) Anti CMV IgG 60,1Au/mL (reactive) Anti CMV IgM 3,8 COI (reactive) Anti HSV IgM/G non reactive AST 224 U/L and ALT 312 U/L

11 Week 6 10 symptom Her fever gradually decrease as well as seizure She is somnolence, with spasticity in extrimities, right hemiplegia, and cortical blindness Latest CT Scan showed cortical infarcts in both hemisphere, multiple lesion without abcess formation, ventriculomegaly due to cerebral atrophy/communicating hydrocephalus CD4 17 cells/ml (5%)

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13 Discussion Cross eye is one of focal deficit that should warrant extraocular or intracranial evaluation The etiology of Nn 3,4 and 6 paralysis usually basal or pontine meningitis/encephalitis with TB (Danish TB Meningitis study, 36%) Window of opportunity to diagnose and manage maybe narrow TB 20 days (5 180) Christensen et al, BMC Infectious Diseases 2011:11:47

14 IRIS (?)

15 Incidence of IRIS Any pathogen (unmasking type) Unselected patient % Cryptococcal treated 23% Cryptococcal (paradoxical), adult 4 50% M tuberculosis (paradoxical) 8 43% French MA, 2000; Jevtovic 2005; Ratnam, 2006, Puthanakit, 2006; Sungkanuparph, 2003; Jenny-Avital, 2002; Shelburne, 2005; Lortholary, 2005; Narita, 1998; Navas, 2002; Breen, 2004; Kumarasamy, 2004; Michailidis, 2005

16 A rapid deterioration of clinical and neurological status following initiation of ART; decrease of HIV-RNA VL greater than 1 log; clinical, laboratory and radiological signs and symptoms consistent with inflammation; lack of correlation between symptoms and a newly acquired infection, a previously present opportunistic infection or drug toxicity Johnson. Curr Opinion Neurol 2011;24:284-90

17 Summary A case of suspected IRIS with manifestation as cross eye (cranial nerve paralysis) Determining diagnosis is difficult with narrow time between appearance of symptom and medication