Welcome to I-TECH HIV/AIDS Clinical Seminar Series
Most Memorable CasesDr Getachew Feleke
January 14, 2010
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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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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+
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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?
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Continued…
Case I Case IISputum 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
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How do you manage these patients?
Case I Case IIHosp. admission Yes No
Antibiotic IV; broad Spec. Amox.(PO)
TMP/SMX Yes (IV) Yes (PO)
Pleural Tap Yes Not done
Supportive Care Aggressive Minimal
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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
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Infectious etiology in HIV(bacterial/fungal)
CD4 Common Less common
>200 Strept. PneumoniaH. InfluenzaM. Tuberculosis
Staph. aureusAtypicals: legionella,mycoplasma,..PCP, Nocardia
50-200 Above organisms PCP
Above organisms CryptococcusRodococcusHistoplasma
<50 Above Above organisms Pseudomonas, Aspergilus
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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
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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
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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.
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Radiologic Finding
Chest x-ray CT chest
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Biopsy Finding“Malakoplakia”
Michael’s Guttmann bodies Foamy macrophages
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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
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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.
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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.
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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
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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.
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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
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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)
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Autopsy Findings
Lung Lung
GMS stain
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Mucicarmine stain
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)
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Cryptococcosis:A major cause of morbidity in AIDS
Cryptococcal Disease Global Burden(Park et al IDSA 2008)
High Income
Countries
Sub Saharan Africa
Incidence <0.1% 3.2%
Case Fatality
9% 70%
#Death/year <10,000 620,000
Prognostic factors in Cryptococcal Meningitis
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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
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1.https://www.plosone.org/article/info:doi/10.1371/journal.pome.005575,2.makadzange (CROI 2008, late breaker
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
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Source: Castelnouve CID 2009; 49;965-72
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
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Thank you!
Next session: January 21, 2010
Dr Roy Colven
HIV Dermatology: Virtual Office Hours
Extra slides
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India Ink
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“Failure to manage elevated ICP is the most dangerous mistake in management”
CID 2005;40:477
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