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ID Case Conference #1 - 1/2/08 Gretchen Shaughnessy, MD Clinical Fellow Dept of Infectious Diseases CC: Fever and Chills 32 YO AAM who presented to UNC ED w/ 2 weeks of fevers and chills in December 2007. Initially had acute onset of fever, chills, and sweats, went to local ED and diagnosed with probable viral syndrome. Developed decreased appetite, weight loss, weakness, sore throat, trouble swallowing, and the sensation of food getting stuck in his throat. During this time he also continued to have fever reaching as high as 105 with night sweats, nausea and vomiting. He went back to his local ED where blood cultures, urine cultures, chest x-ray were WNL. He was discharged on ibuprofen, erythromycin 250 mg b.i.d. for 14 days as well as Percocet and promethazine. HPI Developed mild frontal headache and when he changed position, he felt lightheaded and "wobbly" on his legs. After 2.5 weeks of symptoms he came to UNC ED for further workup, admitted for FUO evaluation Since admission he developed a productive cough with no associated SOB, and watery diarrhea. ID was consulted for assistance PMH History of Chlamydia many years ago that was treated with antibiotics History of a negative HIV test a few years ago (he can't remember the exact date) No other medical problems. Never been hospitalized, never had a surgery. Medications Ibuprofen PRN Erythromycin 250 mg b.i.d. for 4 days Occasional OTC sinus congestion medications No multivitamins or herbs Allergies - NKDA Social History Lives in Fayetteville with his mother. Denies any smoking, illicit drug use or IV drug use ever. He drinks socially (few glasses of wine at dinner). He is currently in a monogamous relationship with his on again/off again girlfriend of 7 years, they are sexually active, do not use condoms. They broke up over the summer and he was sexually active with another woman, but he and his girlfriend got back together by October. He does not know if his girlfriend had other partners while they were apart. He has a 9-year-old son by a different partner who does not live with him. He is employed in construction and paint houses He denies any sexual encounters with prostitutes, sexually active with women only. He has never been incarcerated. No pets at home. No recent travel. Family History His mom has a history of hypertension, diabetes mellitus and is status post thyroidectomy. His father's history is unknown. He is an only child and has a healthy son. He has a maternal grandfather who had heart problems, diabetes mellitus and hypertension. There is no history in the family of genetic disorders or of recurrent infections. ROS Constitutional + Fever/chills, decreased appetite, weight loss, fatigue, weakness Eyes No Double vision, Vision change, Eye pain, or eye redness. ENT + mild Head Ache , sore throat, odynophagia No nasal discharge, neck pain/stiffness Skin/Breast + Draining lesion in the R groin lesion Cardiovascular No chest pain, shortness of breath, or edema Pulmonary + productive cough, no wheeze Gastro Intestinal + watery diarrhea, N/V no constipation, no BRBPR, no hemetachezia, abdominal pain Genito Urinary No frequency, urgency, dysuria, hematuria Musculo Skeletal No myalgia, arthralgia, joint swelling or pain Neurologic No weakness, numbness Physical Exam Vital Tmax : 39.3 Tcurrent : 38.7 Cardiovascular RRR, nml S1/S2, no Pulse : 80-117 M/R/G, 2+ pulses throughout Respiratory Rate : 18-20 Lungs CTAB, no w/r/r Blood Pressure : 116-126/76-86 O2 sat 97% on RA Skin No rashes, 2cm lesion in R groin Thin appearing gentleman in NAD adjacent to scrotum with central opening, no surrounding erythema PERRL, EOMI, sclera clear Erythema in the hard palate, soft palate Abdomen soft, NT/ND, no HSM, no and in both tonsils with some small rebound/guarding pustules scattered throughout thrush Genito Urinary no urethral discharge on tongue and posterior OP. Extremeties no edema Neck supple, no thryomegaly Musculo Skeletal 5/5 strength Non tender LAD in bilateral cervical throughout chains, largest 1.5cm in diameter. several shotty lymph nodes in both Neurological CN II-XII intact, sensation axilla, in the right epitrochlear, in both and strength intact in BU and LE, 3+ popliteal region as well as multiple DTRs symmetrically, no frontal release nontender lymph nodes in the bilateral signs, cerebellar function intact inguinal regions. Labs 140 103 16 100 8.4 1174 110 2.3 0.7 3.9 26 1.5 3.1 666 130 16.8 Venous lactate 1.7 3.4 164 Monospot negative 48.4 Rapid Flu negative N-2.6 Blood cultures x 2 negative L-0.4 Rapid Strep negative M-0.1 Swab of groin wound: E-0.0 3+ SKIN FLORA B-0.0 GC/Chlamydia negative ATYPICAL LYMPHS LD 8393 PLASMACYTOID LYMPHS Radiology Radiology (cont) RUQ U/S – 1. Liver size within normal limits. 2. Lateral to the ligament of teres there is a discrete area of increased echogenicity measuring 1.4 x 1.1 x 1.6 cm, most consistent with focal fat. 3. Mild increased echogenicity of both kidneys adjusting underlying medical renal disease. 4. The spleen measures 11.7 cm in length with a homogeneous echotexture. Discussion “A Diagnostic test was performed…” 12/13/07 Labs from 12/13/07 HIV VL >750,000 ELISA Positive Western Blot Negative CD4 on 12/18/07 Western Blot 12/21/07 The Plot Thickens… 12/21/07 12/27/07 Clinical Presentation of HIV Seroconversion* Schacker, T. et. al. Ann Intern Med 1996;125:257-264 Schacker, T. et. al. Ann Intern Med 1996;125:257-264 Staging of Acute HIV (Fiebig, AIDS 2003) Staging of Acute HIV Staging of Acute HIV CD8+ Response After initial infection there is a immunologic response with large numbers of CD8+ cells Presence of HIV-specific CD8+ cells is associated with viral containment - lower viral load and slower progression to AIDS This expansion of CD8+ cells puts a evolutionary pressure on the virus, which responds with frequent mutations and viral escape Absolute number of CD8+ cells is not associated with better prognosis References Fiebig EW, Wright DJ, Rawal BD, Garrett PE, Schumacher RT, Peddada L, Heldebrant C, Smith R, Conrad A, Kleinman SH, Busch MP. Dynamics of HIV viremia and antibody seroconversion in plasma donors: implications for diagnosis and staging of primary HIV infection. AIDS. 2003 Sep 5;17(13):1871-9. Connick E, Schlichtemeier RL, Purner MB, Schneider KM, Anderson DM, MaWhinney S, Campbell TB, Kuritzkes DR, Douglas JM Jr, Judson FN, Schooley RT. Relationship between human immunodeficiency virus type 1 (HIV-1)-specific memory cytotoxic T lymphocytes and virus load after recent HIV-1 seroconversion. J Infect Dis. 2001 Dec 1;184(11):1465-9. Epub 2001 Nov 13. Betts MR, Krowka JF, Kepler TB, Davidian M, Christopherson C, Kwok S, Louie L, Eron J, Sheppard H, Frelinger JA. Human immunodeficiency virus type 1-specific cytotoxic T lymphocyte activity is inversely correlated with HIV type 1 viral load in HIV type 1-infected long-term survivors. AIDS Res Hum Retroviruses. 1999 Sep 1;15(13):1219-28. Pilcher CD, Fiscus SA, Nguyen TQ, Foust E, Wolf L, Williams D, Ashby R, O'Dowd JO, McPherson JT, Stalzer B, Hightow L, Miller WC, Eron JJ Jr, Cohen MS, Leone PA. Detection of acute infections during HIV testing in North Carolina. N Engl J Med. 2005 May 5;352(18):1873-83. Patterson KB, Leone PA, Fiscus SA, Kuruc J, McCoy SI, Wolf L, Foust E, Williams D, Eron JJ, Pilcher CD. Frequent detection of acute HIV infection in pregnant women. AIDS. 2007 Nov 12;21(17):2303-8. Schacker, T., Collier, A.C., Hughes, J., Shea, T., and Corey, L. 1996. Clinical and epidemiologic features of primary HIV infection. Ann. Intern. Med. 125:257-264. C. D. Pilcher, J. J. Eron Jr., S. Galvin, C. Gay, and M. S. Cohen Acute HIV revisited: new opportunities for treatment and prevention J. Clin. Invest., April 1, 2004; 113(7): 937 - 945. Pantaleo, G., J. F. Demarest, H. Soudeyns, C. Graziosi, F. Denis, J. W. Adelsberger, P. Borrow, M. S. Saag, G. M. Shaw, R. P. Sekaly, et al 1994. Major expansion of CD8+ T cells with a predominant V usage during the primary immune response to HIV. Nature 370:463.
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