CASE-BASED SMALL GROUP DISCUSSION

Transcription

1 MHD II, Session XII, STUDENT Copy Page 1 CASE-BASED SMALL GROUP DISCUSSION Session XII MHD II April 21, 2014 STUDENT COPY Helpful Resource: ACP Medicine online available through LUHS Library Infectious Diseases, Infectious Syndromes, Section 21 HIV and AIDS

2 Case 1 Cc: I tested positive for HIV MHD II, Session XII, STUDENT Copy Page 2 A 43 year-old state representative presents to your office because his HIV test was positive two months previously, at the time of a life insurance evaluation. As a result of the test he revealed his bisexual life experiences to his wife. There has been tension in their marriage since then. Two days ago the wife requested that her husband move out of the home they share with their 5 year old daughter and three year old son. The patient denied fever, any pain, skin problems, diarrhea, weakness, cough or shortness of breath. He admitted to anorexia, a 12 pound weight loss over two months and insomnia. Past medical history: positive PPD since age 5 (treated) and oral HSV since childhood with about 3 recurrences per year. He is on no medications and has no known drug allergies. Physical examination. He is fatigued appearing but in no physical distress. T C, P 84/min, R 18/min BP 122/80. Wt 87.3 Kg; height 71 inches Examination was normal other than a palpable soft, mobile 1 cm. right anterior cervical lymph node and a 0.5 cm left posterior cervical lymph node. Laboratory evaluations 2 months ago (brought by patient) Complete Metabolic Panel Sodium 136 [ ] mm/l Potassium 4.2 [ ] mm/l Chloride 104 [98-108] mm/l CO2 28 [20-32] mm/l Bun 14 [7-22] mg/dl Creatinine 0.9 [ ] mg/dl Glucose 102 H [70-100] mg/dl IMPAIRED FASTING RANGE: MG/DL Albumin 4.0 [ ] gm/dl Protein, Total 8.0 [ ] gm/dl Calcium 9.4 [ ] mg/dl Alkaline Phosphatase 91 [30-110] iu/l ALT (SGPT) 33 [10-40] iu/l AST (SGOT) 39 [5-40] iu/l Bilirubin, Total 1.2 [ ] mg/dl CBC WBC 4.2 [ ] k/ul RBC 5.01 [ ] m/ul Hgb 15.3 [ ] gm/dl Hct 45.9 [ ] % MCV 93.9 [85-95] fl MCH 31.3 [ ] pg MCHC 35.2 [ ] gm/dl RDW 13.8 [ ] % Plt Count 245 [ ] k/ul

3 MHD II, Session XII, STUDENT Copy Page 3 HIV 1 and 2 Ab REPEATEDLY REACTIVE REFERENCE RANGE: NEGATIVE * * * * A REPEATEDLY REACTIVE RESULT WITH THIS ELISA ASSAY MAY INDICATE EXPOSURE TO HIV AND THESE INDIVIDUALS SHOULD BE CONSIDERED INFECTIOUS. A CONFIRMATORY WESTERN BLOT ASSAY WILL BE PERFORMED USING THIS SPECIMEN AS MANDATED BY THE ILLINOIS DEPARTMENT OF PUBLIC HEALTH. * * * * ROUTINE WESTERN BLOT POSITIVE REFERENCE RANGE: NEGATIVE Educational Objectives 1. What test(s) would you order to assess his immune function and level of viremia? 2. What would you tell him about his future sexual experiences? 3. Are all his symptoms attributable to HIV infection? He returns two weeks later. He admits to feeling depressed; he misses his children; and he still has insomnia. His appetite is improved; his weight is unchanged. He has an appointment with a psychologist on the following day. Both of you review the laboratory results.

4 HIV 1 RNA PCR Quant Result: POSITIVE FOR HIV-1: 8,400 COPIES/ML MHD II, Session XII, STUDENT Copy Page 4 THIS TEST SHOULD NOT BE USED FOR THE DIAGNOSIS OF HIV-1 INFECTION AND IS INTENDED FOR USE ONLY IN INDIVIDUALS WITH DOCUMENTED HIV-1 INFECTION. CERTAIN RARE HIV SUBTYPES MAY NOT BE DETECTED BY THIS ASSAY. %CD3+/CD4+ Th CELLS 29 L [30-60] #Cd3+/Cd4+ Th Cells 399L [ ] cmm RPR RPR Qual NON REACTIVE REFERENCE RANGE: NON REACTIVE Toxoplasma IgG Ab INTERPRETATION POSITIVE REFERENCE RANGE: NEGATIVE RESULT 18 iu/ml Anti-HBs INTERPRETATION POSITIVE REFERENCE RANGE: NEGATIVE RESULT 28 iu/ml PPD placed on his left forearm is interpreted as negative. 4. Explain the significance of the laboratory tests. 5. What is the goal of antiretroviral therapy? Is antiretroviral therapy recommended for this patient at this point?

5 MHD II, Session XII, STUDENT Copy Page 5 6. If treatment is recommended, what drug combination(s) should be offered? 7. Significant adverse effects of drugs used to treat HIV. UNKNOWNS - STUDENTS WILL NOT HAVE THE SPECIFICS OF THIS QUESTION UNTIL THE SESSION MEETS

6 MHD II, Session XII, STUDENT Copy Page 6 Case 2 Cc: I have had a fever and cough for the past week. The cough and now shortness of breath are getting worse History: A 47 year-old woman presented with chief complaint of fever to 103 ºF, non-productive cough and dyspnea which has progressed over one week. She was diagnosed with HIV infection 5 years ago at which time her CD4 lymphocyte count was 225. Combination antiretroviral therapy was started, but she stopped taking the medications after one month and did not return to her doctor for follow-up. On review of systems, she has anorexia and lost 70 pounds over the last 3 months. She experiences dysphasia as well. She used heroin and cocaine intravenously for a six month period 6 years ago. She does not smoke or drink, and denies current illicit drug use. She has no past sexually transmitted diseases and is not sexually active. She works as a housekeeper at a hotel. She has no known drug allergies. Physical Examination. She was pale, diaphoretic and in acute respiratory distress. T 38.4º C, P 96/min, R 30/min, BP 110/70, room air oxygen saturation 87%. There were white plaques on an erythematous base on the buccal mucosa and soft palate. Examination of the lungs disclosed bibasilar crackles 2/3 of the way up the posterior lung fields. She had a tachycardia but no murmurs. Her abdomen was nontender, and there was no enlargement of the liver or spleen. Neurologic examination was normal. Initial Laboratory Evaluation: CBC w/diff WBC 7.4 [ ] k/ul RBC 3.15 L [ ] m/ul Hgb 10.8 L [ ] gm/dl Hct 32.0 L [ ] % MCV 82 L [85-95] fl MCH 27.6 L [ ] pg MCHC 31.7 L [ ] gm/dl RDW 15.1 [ ] % Plt Count 125 L [ ] k/ul Diff Type AUTOMATED Gran 43 L [45-70] % Gran # 3.2 [ ] k/mm3 Lymph 41 [20-45] % Lymph # 3.0 [ ] k/mm3 Mono 9 [0-10] % Mono # 0.7 [ ] k/mm3 Eo 6 [0-7] % Eo # 0.4 [ ] k/mm3 Baso 1 [0-2] % Baso # 0.1 [ ] k/mm3

7 MHD II, Session XII, STUDENT Copy Page 7 ARTERIAL BLD GAS (obtained on room air) ph 7.48 H [ ] pco2 30 L [32-46] mmhg po2 51 L [74-108] mmhg HCO3 23 [21-29] mm/l CHEST X-RAY PA AND LATERAL FINDINGS: THERE ARE DIFFUSE BILATERAL INTERSTITAL INFILTRATES. THERE IS BLUNTING OF THE LEFT COSTOPHRENIC ANGLE. THERE IS NO PNEUMOTHORAX. PULMONARY VASCULATURE IS WITHIN NORMAL LIMITS. HEART SIZE APPEARS NORMAL. %CD3+/CD4+ Th CELLS 11 L [30-60] % #Cd3+/Cd4+ Th Cells 107 L [ ]/mm 3 Educational Objectives 1. Develop a problem list. 2. Develop a differential diagnosis for the etiology of this patient s pneumonia. On hospital day #1 sputum was induced with hypertonic saline. Pneumocys Jiroveci (carinii) Smr Specimen sputum induced Description - Special Requests - none direct fluorescence smear positive for pneumocystis jiroveci Culture Results -(carinii) Report Status - final

8 MHD II, Session XII, STUDENT Copy Page 8 Sputum Culture (Final) Specimen Description -sputum Special Requests -none moderate ~white blood cells very few ~squamous epithelial cells few ~gram negative rods Gram Stain - moderate ~gram positive rods sputum evaluation: >25 wbc/lpf, <10 epithelial cells/lpf Culture Results -many colonies of ~normal upper respiratory flora Report Status -final 3. What is the etiology of this patient s pneumonia? Describe the characteristics of the organism. 4. How the cause of this patient s pneumonia acquired? Was this patient recently infected? 5. What is the mechanism by which this organism causes pneumonia? 6. How is infection with this organism diagnosed?

9 MHD II, Session XII, STUDENT Copy Page 9 7. What is/are the drug(s) of choice for treatment of this patient s pneumonia? What are alternative agents? Hospital course: The patient is started on intravenous antibiotics plus prednisone 40 mg twice daily. Two days later she is improved: respiratory rate is 18/min, O2 saturation is 98% with FiO2 of 21%. Antibiotic therapy is changed to the oral route. On day 5, she develops fever, a morbilliform rash and elevations of AST, ALT and alkaline phosphatase. 8. What is the role of corticosteroids in the treatment of this infection? 9. To what can the rash be attributed? What does the term morbilliform mean? Are the rash, fever and abnormalities in liver function related? The students are provided a separate table of infectious (bacterial/viral) exanthems to complete to help with their USMLE prep. If you have questions, please discuss during the small group session 10. Can relapses of pneumonia due to this organism be prevented? How? 11. Review Case Images - Mycology Set 4 Cases 3,4 data provided during small group session.