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

Listserv: itechdistlearning@u.washington.edu

Email: DLinfo@u.washington.edu

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