Gigi Blanchard, MD, of UC San Diego Owen Clinic presents "Clinical Cases"

1. The UC San Diego AntiViral Research Center sponsors weekly
presentations by infectious disease clinicians, physicians and
researchers. The goal of these presentations is to provide the most
current research, clinical practices and trends in HIV, HBV, HCV, TB
and other infectious diseases of global significance.
The slides from the AIDS Clinical Rounds presentation that you are
about to view are intended for the educational purposes of our
audience. They may not be used for other purposes without the
presenter’s express permission.
AIDS CLINICAL ROUNDS

2. Cases
Gigi Blanchard, MD
July 19,2013

3. DK
• DK is a 36yo Indian woman with newly diagnosed
HIV who presented w/ fever and progressively
worsening back pain
• Tested HIV negative in India 2010 prior to her
immigration here
• Late spring of 2012 developed fevers and anorexia
and was diagnosed with HIV by her PCP
• Initial CD4 = 162 (7%); VL = 412,652

4. Chest imaging 7/12

5. 7/12 Admission for pna
• Ruled out for TB with 3 negative AFB smear/cx
• Cryptococcal Ag & Histo negative
• Cocci CF anti-complementary; ID negative
• Bronch wash:
• AFB smear and cx negative; MTD -
• Silver stain negative
• Aspergillus Galactomannan neg
• CSF remarkable for WBC = 50, 94% L
• Defervesced on ceftriaxone

6. 7/12 Admission w/
anaphylaxis
• Another admission for fever (104.6) and cough
• This admission complicated by anaphylaxis
• Infectious w/u repeated and still negative
• Fever and cough treated with 10 days of IV
vanc/aztreonam
• Starts RIL/TDF/3TC + RAL

7. Outpatient F/U
• CD4 = 264 – up from 172
• HIV VL = 207 – down from 400K
• CT chest 8/12:
• Partial resolution of diffuse B/L GGO and
centrilobular nodules compatible with resolving
infection
• Decrease in mediastinal and axillary lymphadenopathy
• ABD CT: Stable to decreased retroperitoneal
lymphadenopathy

8. 8/12 Admission
• Daily fever (102.6), back and leg pain
• No weakness but pain is so bad can’t walk and now has a
rash to oxycodone
• ROS is o/w negative
• MEDS:
• RIL/TDF/FTC + RAL
• Lorazepam
• Zolpidem
• Oxycodone

9. • ALL:
• Augmentin
• Ceftriaxone
• Cipro
• Doxycycline
• Fluconazole
• SMP/TMZ
• Azithromycin
• Morphine
• Micafungin
• Shx:
• No tob
• No etoh
• No drugs
• Not sexually active
• Fhx:
• Dad has DM
• Aunt with breast cancer

10. T 102.5 P 104 BP 118/76 RR 16
• GEN: tearful but in no other distress
• HEENT: OP clear; no icterus
• PULM: CTA B/L
• CV: Tachycardic, no M
• ABD: soft, NT, ND, NABS; no HSM
• BACK/EXT: No spinal tenderness; tender over L SI
joint; no edema
• NEURO: Moving all extremities; DTRs WNL

11. • Na 131, K 3.9, Cl 99, Bicarb 19, BUN/Cr nl
• AST/ALT: 44/45, ALB 3.8
• WBC = 8.9, H/H = 9.9/30; Plt = 384
• S 36 L 51 E 6
• Sed rate = 99; CRP 6.2
• CD4 = 264; VL = 207

12. MRI Lumbar Spine

14. 8/12 Admission
• IR unable to aspirate the SI joint but did do a wash-
out
• WBC 90 (44% PMNs, 44% Lymphocytes, 4% Eos,
8% maacrophages)
• Aerobic Culture: Negative
• Anaerobic Culture: Negative
• AFB Culture: Negative

15. Admission Sacroiliitis
• Brucella Ab <1:20
• Bartonella Ab < 1:64
• Strongyloides Ab 0.03 negative
• Lyme 0.26 negative
• Coxiella burnetti Ab negative
• Cryptococcal Ag negative

16. 8/12 Admission
• 8/13/12 Cocci CF Anticomplementary; ID negative
• Numerous bacterial, AFB and fungal cx negative from
blood, CSF
• Quantiferon negative
• TEE negative

17. A New Result
• 8/18/13 Cocci CF + 1:16
• Total body bone scan negative
• CSF studies are normal/negative
• Desensitized to fluconazole and started on 400mg
bid

18. 18
Case DK
July 3-5 July 20 Aug 13 Aug 18 Aug 24
Cryptococcal
antigen (serum)
Negative Negative Negative
Histoplasma
antigen (urine)
<2.0 (neg) <2.0 (neg) <2.0 (neg)
Coccidioides
immunodiffusio
n (ID)
Negative Negative Negative Negative
Coccidioides
complement
fixation (CF)
Anti-
complementar
y
Anti-
complementar
y
Positive 1:16 Positive 1:16

19. Coccidioides

20. Coccidioidies: forms

21. • Endemic to arid SW
• Arizona, California,
Nevada, New Mexico &
Utah
• Parts of Central and South
America

22. Clinical Manifestations
• 50-70% of infections are asymptomatic or so mild
that they don’t come to medical attention
• Usually self-limited
• Complications manifest weeks to 2 years later
• The severity of the initial infection does not correlate
with the likelihood of complications
• Highly infectious (transferring planes in Phoenix)
• 1 arthroconidium is enough

23. Clinical Manifestations
• Early respiratory infection
• Sx develop 7-21 days after exposure
• Onset is usually subacute but can be abrupt
• 70-75% have fever and cough
• 30-40% have chest pain (pleurisy), dyspnea and fatigue
• Weight loss is common
• HA occur ~ 20% of the time
• Rash: fine papular rash, e nodusum, e multiforme
• Migratory arthralgias are common

24. Pulmonary Findings
• Unilateral infiltrates, hilar adenopathy & effusions
• Nodules – Peripheral & Solitary
• Cavities ~ 8% of the time
• Usually thin walled
• May develop a mycetoma
• Diffuse pulmonary (reticulonodular) infiltrates more
common in HIV
• May mimic septic shock
• Chronic Fibrocavitary Pneumonia

25. ExtraPulmonary
Dissemination
• Only 0.5% in general population
• Much more common in immunosuppressed
• AIDS (CD4 < 100)
• Transplant pts
• Pts on chronic steroids (prednisone 20mg)
• Hodgkin’s lymphoma
• More common in men than women (unless she’s
pregnant)

26. ExtraPulmonary
Dissemination
• Skin: maculopapular lesions to ulcers to abscesses
• Joints and bones – any joint can be involved
• Synovitis and effusion
• Knee; hands and wrists; feet and ankles and the pelvis
• Infection may erode to involve bone as well
• Vertebral infection is not uncommon with multiple
vertebrae involved & may see paraspinous abscesses
• Meningitis (eosinophilia in CSF in add’n to usual
abnormalities)

27. Diagnosis
• Delayed-type hypersensitivity testing
• + for life
• Anergy: May be negative during active infection
• Direct Examination and culture
• Serology

28. Diagnosis: Direct exam/cx
• Identifying spherules in a specimen
• Sputum is not infectious
• Can’t be detected by Gram Stain
• Cytology stains; H&E, silver or PAS stains all work
• Grows well on most fungal or bacteriologic media w/in
1 week -
• NOTIFY THE LAB - this culture is highly infectious

29. Serologic Diagnosis
• + Antibodies in serum, CSF or other fluid
• Highly specific
• Even minimally reactive results are significant
• A negative test NEVER excludes infection
• Repeat tests over 2 months to increase sensitivity
• Titer >1:16 ass’d with dissemination
• Does not cross react with Cryptococcus or Blasto and
very rarely with Histo

30. Immunodiffusion
• Antigen is incorporated into
the gel or agar
• Serum (antibody) is added
to wells, which then diffuses
through the Antigen
containing gel
• Precipitate/ring forms
• IgM

31. 32
Complement Fixation
Disease
No
disease
Control
(no test
antigen)
Notes
Control
(no test antigen)
Heat (remove
native
complement)
Add test antigen
(coccidioidin)
Add
standardized
complement
Incubation
Add sensitized
sheep RBCs coated
with hemolysins
Reaction (RBC
plug vs
Y Y Y Y
Y Y Y Y
Y Y Y Y
Y Y Y Y
Y Y Y Y
Y Y Y Y
OK Anticomplementary

32. Back to DK
• She remains afebrile
• Back pain due to anterolisthesis remains severe
• Re-admitted 10/12 for out of control pain
• Repeat MRI:

35. • A diagnostic procedure is performed

36. Non-Hodgkin’s Lymphoma!!

37. Terry
• Terry is a 41yo AA M-to-F with a CD4 = 196 (12%)
, VL = 167 in 6/11 who presented to UCSD’s ED
10/12 with several complaints
• Had been out of care since 6/11 d/t meth abuse
• + dysphagia for solids x 10days; no odynophagia
• Abd pain
• Chest pain – in the ED, ass’d with EKG
abnormalities

38. Terry
• Abd pain – epigastric x 1 week
• + N/V; No D or constipation
• Not ass’d with eating; no radiation
• Wakes her up at night
• Chest Pain in the ED
• Substernal, stabbing; No radiation
• No palpitations; no DOE; no syncope; no orthopnea
• Smoked meth on the day of admission
• Resolved with ASA and nitro

39. Terry
• ROS:
• + anorexia with ~ 20lbs weight loss over 2 mo
• F x 2 weeks – as high as 110!; NS x 2 week
• No HA; No visual problems; no oral
lesions/pain
• No easy bruising; epistaxis or bleeding gums
• + dry cough; no pleurisy
• No pedal edema; no DOE; No orthopnea
• No rash

40. Terry
• PMHx
• HIV, dx’d in ‘03
• Syphilis
• Meds: None
• ALL: NKDA
• Shx:
• on disability
• No tob, etoh
• Smoked meth 2 weeks ago and on the day of admission
• Fhx: mother has DM; Dad A&W

41. T 97 P119 BP 106/70 RR 22 100%
• GEN: thin AAM in NAD
• HEENT: poor dentition but no thrush or lesion
• PULM: CTA B/L
• CV: tachy, but no M/R/G
• ABD: soft, NT, ND, NABS; no HSM
• EXT: no edema
• LN: no cervical, axillary, inguinal LAD

42. Labs
• Na = 131, BUN/Cr = 22/0.17
• Cl = 89, Bicarb = 17
• SGOT/SGPT = 53/17; albumin = 2.6
• AG = 27.5; Lactate = 91.1
• Lipase = 16
• CPK-MB = 9.2 (nl <4.8);
• Troponin T = 0.53 (nl < 0.01; >0.09 = MI)

43. Labs
• WBC = 6.8; H/H = 10.9/33.4; Plt = 232
• MCV = 76.1, RDW = 20.9
• S 77; B 3; L 10
• UA: 1.027, 1+ protein; no glu; moderate ketones; 3-
5 WBC; 6-10 RBC; many squames
• U tox = + amphetamine; BAL < 9
• Blood cx – pending

45. Bedside Echo

46. Cardiac Masses
• Infections/endocarditis
• Bacteria
• Mycobacteria
• Fungi
• Candida
• Aspergillus (intracardiac masses have been described)
• Cryptococcus

47. Cardiac Masses
• Thrombi (cluster of grapes; trapped in the chords)
• Structural Abnormalities
• False tendons (ventricular muscle band that goes from
muscle to muscle rather than muscle to valve and it
spans the chamber)
• Moderator bands (carry the R bundle branch in the RV)
• Ruptured chordae tendinae

48. Cardiac Tumors
• Sx depend on size and location
• Chest pain, syncope, heart failure
• Arrhythmias, murmurs, pleural effusions
• Metastatic disease more common than primary
tumors
• Melanoma, lymphoma most common by incidence
• Lung and breast most common by number
• Usually nodules or pericardial involvement; chamber
involvement less common

49. Primary Cardiac Tumors
• Myxoma
• Most common benign tumor
• 1/3 of all primary cardiac tumors
• 75% involve the LA at the fossa ovalis
• 15% involve the RA
• Usually solitary unless part of a syndrome
• Occur typically in the 3rd to 6th decades
• Women > men
• Sx are those of obstruction, emboli or constitutional sx

50. Primary Cardiac Tumors
• Sarcoma
• Most common malignant primary cardiac tumor
• ~ 40% are angiosarcomas
• Usually in the RA
• Well defined mass
• Sx: R sided heart failure or tamponade d/t frequent
pericardial involvement
• Bloody pericardial fluid usually has no malignant cells
• Undifferentiated, rhabdomyosarcoma (arises from
valves), osteosarcoma and leiomyosarcoma

51. Primary Cardiac Tumors
• Kaposi’s Sarcoma
• Cardiac involvement much more common when
cutaneous disease (20% of an autopsy series)
• Similar to cutaneous disease, see violaceous plaques
and nodules
• Usually multiple sites:
• Pericardium, epicardium, subepicardium & myocardium
• Usually asymptomatic and only found at autopsy

52. Primary Cardiac Tumors
• Primary cardiac lymphoma
• Usually involves the RA
• Pericardial involvement is common but not extension into
the valves
• Metastatic (secondary cardiac lymphoma)
• Typically aggressive B-cell lymphomas
• Present anywhere in the heart
• Pericardial, epicardial or diffusely infiltrative
• Sx: dyspnea, CHF, CP, epigastric pain
• Tamponade, arrhythmia
• MI simulated by diffuse myocardial infiltration

53. More Labs and imaging
• LDH: 5640!! uric acid = 11.2
• CT C/A/P: Large ill-defined mass in the LUQ
causing mass effect on multiple structures w/o
definitive evidence of invasion. The left kidney is
displaced inferiorly and the spleen superiorly.
• There is mass effect on the splenic vein and artery
and the L renal vein and artery w/o evidence of
invasion.

54. • FNA of RP mass: High grade B-cell lymphoma c/w
Burkitt’s Lymphoma
• Started on hydration, alkalinazation, and allopurinol
• R-EPOCH

55. F/U Echo

56. F/U Echo

57. Ready for a quickie?

58. JP
• 26yo with no PMHx presented to UCSD’s ED 5/13
with h/o cough and dyspnea since Sept
• Intermittent fevers
• Seen in urgent care 10days ago and given course of
doxycycline
• ROS + for 20lb weight loss

59. JP

60. JP

61. JP

62. 63
Questions

63. Thank you!