Clinical presentation Opportunistic infections
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1 Clinical presentation Opportunistic infections Assoc Prof. Thanyawee Puthanakit Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University,Bangkok, Thailand HIVNAT, Thai Red Cross AIDS Research Center
2 Case KB 18 year-old HIV-infected girl Perinatally HIV infection diagnosed at 11 years of age CDC cat C3: Lymphoid interstitial pneumonitis, wasting CXR: bilateral interstitial infiltration No Hx. of contact TB Sputum AFB; negative * 3 days BW 16 kg, 117 cm CD4 = 1%, 30 cell/mm3 12 Sep 2003
3 Date KB: ARV history-clinical course Age (yr) BW (kg) Ht (cm) CD4 % (count) Viral load (copies/ml) Clinical Treatment 11/ (30) LIP d4t+3tc+nvp Bactrim 05/ (176) 11/ (197) 16,800 L210W, T215Y, M184V, Y188L 02/ (274) 23,200 chronic cough 09/ (271) 14,000 02/ (28) 147, 647 Fever, purulent productive cough Adherence Ix AZT+3TC+LPV/r TDF+3TC+LPV/r Bactrim
4 KB: pulmonary symptoms 12/2010 Date BW (kg) CD4 % (count) Clinical 02/ (28) Fever, purulent productive cough Sputum AFB ve * 3 days Dx: infected bronchiectasis 09/ (7) Cough, bloody sputum, no fever, dyspnea Sputum AFB &PCR for TB* 3 days : negative Sputum C/S for TB; pending Dx: infected bronchiectasis 12/ (2) Fever* 10 days with productive cough Oral candidiasis Treatment TDF+3TC+LPV/r Bactrim Amoxi-clav TDF+3TC+LPV/r Bactrim Amoxi-clav Ciprofloxacin
5 Generalized bilateral increase lung marking 22 Feb Sep 2010
6 13 Dec 2010
7 Q1: What is the most likely diagnosis? A. Infected Bronchiectasis B. Pulmonary tuberculosis C. Pulmonary Norcardiosis D. Rhodococcus pneumonia E. Cryptococcal pneumonia
8 Dec 2010: pulmonary problems Date CD4 % (count) Clinical 13/12/ (9) Fever * 10 days with productive cough CXR; as shown Sputum AFB ve * 3 days Sputum gram stain:mixed organism Blood culture: no growth 10/01/2011 Productive cough, wt loss 2 kg/2 wks CXR, sputum AFB, mafb Treatment INH Rifampicin Pyrazinamide Ethambutol Ceftriaxone
9 Sputum gram stain 10 Jan 2011 After TB treatment 1 month Sputum modified AFB
10 Q2: What is the most likely diagnosis? A. Pulmonary tuberculosis B. Pulmonary tuberculosis- MDR C. Pnuemonia-nontuberculous mycobacterium D. Pulmonary Norcardiosis E. Rhococcocus
11 Feb-Apr 2011: pulmonary problems Date BW (kg) CD4 % (count) VL (c/ml) ART Clinical OI Treatment 01/ TC Nocardiosis Cotrimoxazole IV oral switch 07/03/ (16) TDF/3TC/LPV/r CXR: decrease RUL infiltration 19/ 04/2011 ( 6 weeks after ART) 26.6 TDF/3TC/LPV/r Fever, productive cough, dyspnea
12 7 March 2011 Restart ART 19 April 2011 Week 6 ART Sputum mafb: positive Treatment: Co-trimoxazole IV
13 25 April May 2011 Week 10 of ART Sputum mafb: negative Treatment: Co-trimoxazole IV 3 weeks and oral switch on 10 May 2011
14 24 May 2011 ( week 12 of ART) Progressive headache with ataxia Finger to nose test: sway (left), hyperreflexia (left) Q3: What is the most likely diagnosis? A. Tuberculoma B. Cryptococcoma C. Toxoplasmosis D. Brain abscess (Nocardia) E. Progressive multifocal leukoencephalopathy
15 Nocardia brain abscess-iris? 24 May 2011 Surgery: Burr hole Operative finding: Frank green pus 22 ml Gram stain: no organism AFB & mafb : no organism Aerobe/anaerobe culture: neg Serum crypto antigen: neg 7 Mar 2011: CD4 1%, 16 cell/mm3, HIV RNA 32,969 copies/ml 24 May 2011: CD4 6%, 163 cell/mm3, HIV RNA 863 copies/ml
16 Nocardia brain abscess-iris? June 2011 Rx: co-trimoxazole IV 3 weeks (24 May 16 June 2011) Can walk by herself in balance Neuro sign: Improved finger to nose Lt. side Take ARV regularly
17 Case summary: Opportunistic infection An 18 year old perinatally HIV-infected adolescent with poor adherence to ART Presentation: LIP with subacute pneumonia mimicking tuberculosis Diagnosis: Pulmonary nocardiosis Complication: during immune recovery period Worsening of lung abscess Brain abscess Outcome: Survive on second-line ART
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