MAKING THE CASE FOR HIV TESTING Douglas Fish, MD Kevin O Reilly, MD Stefanie Neubert, NP Amy Bagenski, MS III Albany Medical College June 4, 2013

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1 MAKING THE CASE FOR HIV TESTING Douglas Fish, MD Kevin O Reilly, MD Stefanie Neubert, NP Amy Bagenski, MS III Albany Medical College June 4, 2013 CASE PRESENTATION: HPI CC: A 33 y/o Caucasian male with no significant PMH, who presented to the ED with painful swallowing and a rash. Odynophagia with solids & liquids began 2 days prior to admission. C/o 2 weeks of weakness, fatigue, and a 10 pound, non-intentional weight loss. Had subjective fevers and night sweats 3 days prior to admission. He also had nonbloody, mucoid diarrhea for the past 3 days. He had an intermittent, dry cough. 1

HPI CONTINUED Rash/lesions begin 2 months ago, but he decided to wait to see if they would resolve on their own. Instead, the lesions enlarged and spread to his face, arms, and trunk.

2 HPI CONTINUED Rash/lesions begin 2 months ago, but he decided to wait to see if they would resolve on their own. Instead, the lesions enlarged and spread to his face, arms, and trunk. He described the rash as nonpainful and nonpruitic. He denied any shortness of breath, chest pain, abdominal pain, hematochezia, headache, photophobia, neck stiffness, dysuria, hematuria, genital rash or discharge. He denied any recent travel or sick contacts. He reported that he was tested for HIV 2 years ago and was found to be negative. 2

3 PMH AND PSH PMH Oral herpes PSH None Allergies Sulfa-containing medications Reaction - hives 3

4 MEDICATIONS No Rx medications O.T.C. medications Acetaminophen for occasional HA every few weeks Ibuprofen for occasional HA every few weeks Antacids for occasional acid reflux Multivitamin taken once daily, started a few months prior SOCIAL HISTORY Well educated 30 y/o male He is a homosexual male; his last intercourse was 1 year ago - receptive anal intercourse. He was not using protection. He has had 8-9 partners in his lifetime. He lives with a roommate currently and does not have a partner. He smokes 2-3 cigarettes per day for 15 years; he quit 2 weeks ago, because I knew something was wrong. He drinks alcohol socially and has not used recreational drugs. His roommate has a cat. 4

5 PHYSICAL EXAM FROM THE ED Vitals: Temp: F BP: 125/83 HR: 146 RR: 24 O2 Sat. at RA: 93% General: Thin, ill-appearing male, though not toxic. HEENT: Oral mucosa dry, with white patches seen throughout the mouth, and 2 violaceous lesions on the hard palate. Neck supple w/o appreciable lymphadenopathy. Multiple, raised, nodular, nonpruitic, violaceous lesions on his face, eyelid and palate. CV: Tachycardic; normal S1 and S2; no murmurs/rubs. Resp: Clear to auscultation bilaterally. PHYSICAL EXAM -CONTINUED Abdomen: Soft and nondistended. No masses, tenderness or organomegaly. Extremities: No edema. Neuro: Motor and sensory function intact. Psych: Alert and oriented to person, place, and time, with appropriate thought content. Skin: Scattered, raised violaceous plaques of approximately 1-2 cm in diameter on his face, neck, arms, back and trunk. 5

6 LABS FROM ED CBC WBC:10,200 - Lymphocytes 9%, with absolute lymphocyte count of 0900 H/H: 11.5/34.5 Plt:207,000 BMP and LFTs normal LDH:271 Albumin: 2.9 g/dl Labs for anemia Iron-25, TIB-162, Ferritin-904, VitB12 and Folate WNL IMAGING-CXR Significant for prominent interstitial markings. 6

HIV STATUS-ED Rapid HIV 1/2 EIA Test - Positive HIV Hospital Course 4 th generation HIV Antibody-antigen (HIV - 1/2/p24Ag) screen during hospital course - Positive HIV Western Blot - Positive CD4

7 HIV STATUS-ED Rapid HIV 1/2 EIA Test - Positive HIV Hospital Course 4 th generation HIV Antibody-antigen (HIV - 1/2/p24Ag) screen during hospital course - Positive HIV Western Blot - Positive CD4 count - 6 cells/cmm Viral load - 187,000 copies/ml Negative for Hepatitis A, B and C RPR nonreactive INTERSTITIAL PNA-HOSPITAL COURSE ph-7.45, PCO2-35, PO2-73, HCO3-24 on room air) A-a Gradient - 33 mmhg; elevated, but <35mmHg. 7

8 INTERSTITIAL MARKINGS ON CXR, WITH DECREASED O2 SATURATION ON ROOM AIR Differential diagnosis: Pneumocystis jirovecii pneumonia Mycobacterium tuberculosis Cytomegalovirus pneumonia Cryptococcal pneumonia Disseminated Kaposi s sarcoma Mycoplasma pneumoniae BRONCHOSCOPY Lesions consistent with Kaposi s sarcoma found on vocal cords, trachea, and right and left main stem bronchi. Bronchoalveolar lavage AFB culture and smear-smear negative; culture ultimately negative. BAL found positive for CMV and HSV by PCR. Negative for Mycoplasma pneumoniae. No CMV retinitis by ophthalmology consult. Negative for cryptococcus on fungal culture, and bacterial culture found only normal flora. Cytology Pneumocystis jirovecii organisms present in BAL. 8

9 TREATMENT COURSE -PJP Trimethoprim-sulfamethoxazole - Not an option, due to an allergy resulting in hives. Atovaquone (Mepron) suspension - 750mg/5mL bid. FDA-approved for mild-moderate PJP po2>70; A-a gradient<35 ODYNOPHAGIA Differential Diagnosis Candidial Esophagitis Cytomegalovirus Esophagitis Herpes Simplex Esophagitis Gastroesophageal Reflux Disease Malignancy 9

10 ODYNOPHAGIA-WORKUP AND HOSPITAL COURSE The patient empirically started on fluconazole IV. EGD- Linear esophageal ulcers with no evidence of bleeding, from mid-esophagus to gastroesophageal junction. Recommendation from GI was esomeparazole (Nexium) 40 mg bid. Biopsies taken and sent to pathology. Significant for Herpes Simplex Virus inclusions with immunostaining No evidence of Cytomegalovirus inclusions. Treated first with IV gancivlovir, then acyclovir after biopsies returned RASH Differential diagnosis based on clinical description Kaposi s Sarcoma - HHV8 Bacillary Angiomatosis Melanoma 10

11 RASH-WORKUP AND HOSPITAL COURSE Skin - violaceous lesions on arms, back, trunk, palate, neck, and right lower eyelid found to be nonpruitic, nontender, and nonblanching. Skin biopsy confirmed Kaposi s Sarcoma. KAPOSI S SARCOMA-TREATMENT The first-line treatment was starting the patient on HAART. Due to the extent of his lesions and possible visceral involvement, doxorubicin (Doxil) was started as an outpatient after HAART initiation, as chemotherapy treatment for the numerous lesions. 11

SUMMARY OIS/MALIGNANCY & F/U Pneumocystis pneumonia Candidial esophagitis Herpes simplex esophagitis Disseminated cutaneous Kaposi s sarcoma Started on

12 SUMMARY OIS/MALIGNANCY & F/U Pneumocystis pneumonia Candidial esophagitis Herpes simplex esophagitis Disseminated cutaneous Kaposi s sarcoma Started on FDC tenofovir/emtricitabine/efavirenz (Atripla) Current CD4 Current viral load < 40 copies/ml HIV Care and Treatment Cascade MMWR #60; ;

COMMUNITY VIRAL LOAD (CVL) Mean CVL was calculated as the mean of the most recent viral load of all reported HIV-positive individuals in a particular community.

13 COMMUNITY VIRAL LOAD (CVL) Mean CVL was calculated as the mean of the most recent viral load of all reported HIV-positive individuals in a particular community. Total CVL was defined as the sum of the most recent viral loads of all HIV-positive individuals in a particular community. Das et al. PLoS One. 2010; 5(6): e

14 San Francisco, CA Das et al. PLoS One. 2010; 5(6): e11068 San Francisco, CA Das et al. PLoS One. 2010; 5(6): e

15 TAKE-HOME POINTS Offer HIV testing widely Risk factors increasingly irrelevant Test, test, test 15

Clinical Manifestations of HIV

HIV Symptoms Diane Havlir, MD Professor of Medicine and Chief, HIV/AIDS Division University of California, San Francisco (UCSF) WorldMedSchool; July 2, 2013 1 Clinical Manifestations of HIV! Result from