12/13/19 Great Cases From the Bay Ayesha Appa, MD Annie Luetkemeyer, MD Hyman Scott, MD Carina Marquez, MD Division of HIV, Infectious Diseases, and Global Medicine University of California, San Francisco Zuckerberg San Francisco General Hospital 1 Disclosures • Drs. Appa, Scott, and Marquez do not have disclosures. • Dr. Luetkemeyer reports research grant support to UCSF from AbbVie, Gilead, Merck, Viiv. 2 1
12/13/19 H- -V CASES Presented By: Ayesha Appa, MD 3 DISCLOSURES • None 4 2
12/13/19 CASE 1 OF 2 5 HIV (UNDETECTABLE VIRAL LOAD + CD 284, 20%) AND RIGHT EYE PAIN, DRAINAGE, AND VISION LOSS AFTER A FALL 6 3
12/13/19 58 yo man with HIV (CD4 284, suppressed VL) and R eye pain, drainage, vision loss. HPI • Ground-level fall 3 days ago • Denies overt eye trauma Rapid progression of • symptoms PMH • HIV – on ABC/3TC/DTG Schizophrenia • SH Veteran, lives with dog in • single-room occupancy • Sexually active with women 7 58 yo man with HIV (CD4 284, suppressed VL) and rapidly progressive R eye pain, drainage, vision loss after a fall. Hospital Course • Immediately taken to the operating room: ” Massively purulent keratoconjunctivitis with corneal melt , leading to panopthalmitis.” • Required enucleation (surgical removal of globe). 8 4
12/13/19 OCULAR ANATOMY BASICS 9 ANTERIOR SEGMENT VS. POSTERIOR SEGMENT 10 5
12/13/19 CONJUNCTIVA Kaposi Sarcoma ANTERIOR SEGMENT Keratoconjunctivitis Sicca HSV keratitis VZV keratitis Bacterial/fungal keratitis Microsporidia keratopathy Rifampin-induced anterior uveitis POSTERIOR SEGMENT HIV retinopathy CMV retinitis VZV retinitis Toxoplasma chorioretinitis TB chorioretinitis Syphilis chorioretinitis USE THIS APPROACH FOR HIV-RELATED EYE INFECTIONS! Cunningham E. “Ocular Manifestations of HIV Infection.” NEJM 1998. 11 CASE 2 OF 2 12 6
12/13/19 HIV/AIDS (VL 70K + CD 112, 12%) AND RIGHT EYE PAIN, DRAINAGE, AND VISION LOSS FOLLOWING TRAUMA 13 62 yo man with HIV (CD4 112, 12% + VL 70k), with R eye pain, drainage, and vision loss. HPI • When gardening 5 days ago, thinks tree branch struck his eye. PMH • HIV/AIDS – off ARVs x 2 years SH • Lives in suburbs with husband, only sexually active with him. 14 7
12/13/19 62 yo man with HIV (CD4 112, 12% + VL 70k), with R eye pain, drainage, and vision loss. Ophthalmology describes as: Purulent Keratoconjunctivitis with Corneal Ulcer 15 CASE SUMMARY Case 1 Case 2 Middle-aged African-American veteran Middle-aged affluent Caucasian man who with history of schizophrenia who lives enjoys gardening and lives in the suburbs alone in a single-room occupancy. with his husband. HIV VL suppressed HIV/AIDS VL 70k CD4 284, 20% CD4 112, 12% “I got something in my eye...” Purulent keratoconjunctivitis Purulent keratoconjunctivitis with corneal melt with corneal ulcer Dramatically purulent inflammation of anterior surface that rapidly progressed to involve the entire globe. 16 8
12/13/19 DIFFERENTIAL AUDIENCE RESPONSE What is the causative organism for both cases? A. Staphlyococcus aureus B. Pasteurella multocida C. Neisseria gonorrhoeae D. Treponema pallidum E. Sporothrix schenckii 17 DIFFERENTIAL? ANTERIOR POSTERIOR SEGMENT SEGMENT 18 9
12/13/19 DIFFERENTIAL? Clinical pearl from Ophthalmology: Only 3 bacterial pathogens that have ability to penetrate* an intact cornea… ANTERIOR Neisseria gonorrhoeae SEGMENT Listeria Keratoconjunctivitis Corynebacterium *People living with HIV may have other reasons for corneal disruption. 19 In both cases, the culture grew… NEISSERIA GONORRHOEAE 20 10
12/13/19 GONOCOCCAL CONJUNCTIVITIS Gonococcal conjunctivitis can affect adults! History may not be straightforward given inoculation of the eye may occur in many ways; concurrent GU disease not always present. Lessing JN, et al. “Hyperacute Gonococcal Keratoconjunctivitis.” JGIM: March 2019. 21 GONOCOCCAL CONJUNCTIVITIS • Conjunctivitis may quickly progress to corneal ulceration and panopthalmitis (both vision-limiting) within days. Lessing JN, et al. “Hyperacute Gonococcal Keratoconjunctivitis.” JGIM: March 2019. 22 11
12/13/19 CASES IN CONTEXT INCIDENCE OF GONORRHEA RISES https://www.cdc.gov/std/stats18/ 23 CASE CONCLUSIONS • Both patients were treated with CEFTRIAXONE 1G IV + AZITHROMYCIN 1G PO per CDC guidelines. • First patient received a scleral implant, recovered well despite losing his globe. • Second patient slowly recovered, retained ability to see light/shapes. 24 12
12/13/19 Case 3 Presented by: Annie Luetkemeyer, MD 25 Ca Case • 48 year old Eritrean man, presented to ED with abdominal pain, back pain, fevers, and 30 pound weight loss over several months • New diagnosis of HIV, CD4 68 (7%) in ED • Physical Exam • No lymphadenopathy • Mild abdominal tenderness • No palpable hepatosplenomegaly, no spine tenderness • No skin lesions • Admitted for further evaluation 26 13
12/13/19 1. Abnormal soft tissue thickening around the abdominal aorta. Hyperdense foci within the soft tissue. 2. A wedge shaped region of hypodensity in the posterior left kidney may represent a small infarct. 3. Splenomegaly. 27 Patient history • Sexually active with women, thinks this was his route of HIV infection • Currently works as a taxi driver. • Travels back to Eritrea every few years for several months at a time to a rural area with goats, cows, dogs, cats • Eats raw beef (Eritrean delicacy) occasionally • No alcohol, drugs, tobacco 28 14
12/13/19 Additional Evaluation • Chest imaging: no thoracic aortic involvement. Normal lungs • Labs • CBC: Hematocrit 26.7 • Microbiology • RPR (-), TPPA inconclusive • Toxoplasma IgG (+) • Quantiferon (-), AFB blood cultures: smear negative, cultures no growth • Blood cultures: no growth • Fungal serologies: Cryptococcus, Histoplasmosis, Cocci all negative 29 ARS question: What is your diagnosis? A. Salmonella B. Mycobacterial (TB or MAC) C. Bartonella D. Syphilis E. Parasitic infection from beef or goats 48 year old Eritrean man, new AIDS diagnosis, abdominal aortitis 30 15
12/13/19 ARS: What would you do to make the diagnosis A. Biopsy the aorta B. Are you crazy? You can’t biopsy the aorta- provide empiric treatment for TB/MAC, monitor closely for anything else to biopsy and wait for mycobacterial cultures 31 FNA Biopsy: “Occasional rod-like structures. Rare atypical AFB”. AFB staining & culture in microbiology lab : Negative 32 16
12/13/19 Initial Initial Trea eatm tmen ent t Plan Plan • ART already started on admission • Initiated empiric MAC/TB therapy • Pain significantly improved after several weeks • Path sent to UW for Molecular Diagnostics to determine TB vs. MAC by PCR returns: PCR: Bartonella Quintana (!) 33 Ba Bart rton onella • B. henselae : flea bites, cat bites/scratches • B. quintana- lice infestation, homelessness • “Typical” bartonella: cat scratch disease with lymphadenopathy, bacillary angiomatosis bacteremia, hepatic/bone, endocarditis Peliosis Hepatis Axillary lymphadenopathy Bartonella Osteomyelitis Bacillary Angiomatosis 34 17
12/13/19 Take Homes • Bartonella in US often associated with homelessness and/or lice, but not always the case. • Be vigilant of atypical presentations of disease in AIDS. • PCR-based diagnostics have become powerful tools to diagnosis challenging infections (and sometime lead to surprising results!) 35 Case 4: Patient with Fever and Bone Lesions Presented by: Hyman Scott, MD 36 18
12/13/19 Case Presentation • 52 yo man with HIV (CD4 534, HIV VL <40) developed sore throat and odynophagia, as well as nasal congestion and rhinorrhea. • Diagnosed and treated for strep throat (culture positive). He was treated with Clindamycin 10days with complete resolution of symptoms. • Subsequently developed subacute weakness, headache, malaise, and approximately 10lb weight loss, fevers, drenching night sweats, and malaise. 37 Objective Ill appearing and febrile (102.6). Exam WNL, No LAN All labs and imaging normal except: Microbiology Imaging Influenza A – Positive CT Chest – Scattered areas of GGO, and tree- RPR – 1:16 (serofast) in-bud nodularity in RUL, and RLL>LLL. CT Abd – Large lytic lesion in left iliac crest, other nonspecific lucency throughout the bony pelvis 38 19
12/13/19 Lytic Lesion 39 Course • During his inpatient stay: • He was treated with Tamiflu for Influenza A • Bone biopsy: “Skeletal muscle with focal new woven bone formation and crushed cells” • Clinic follow-up with some improvement in symptoms • Another laboratory test was sent and repeat bone biopsy 40 20
12/13/19 ARS What would be highest on your DDx for this patient’s lytic lesion? 1. This is a malignancy, just not sure which one yet. 2. Syphilis 3. TB 4. Sarcoid 41 Syphilis testing 1/15 1/26 (Inpatient) 1:16 1:1024 42 21
12/13/19 Necrosis Inflammation H&E, 40x Granulomatous inflammation with necrosis 43 Reactive woven bone Necrosis H&E 100x Osteonecrosis 44 22
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