ID Case Conference #1 - 1/2/08 by 6BH2D9

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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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