hypothermia in an hiv-infected patient
DESCRIPTION
J. Tyler Longeran, MD (UC San Diego Owen Clinic) presents "Hypothermia in an HIV-infected Patient"TRANSCRIPT
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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
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Hypothermia in a HIV-infected patient
J. Tyler Lonergan, M.D.
February 8, 2013
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Presentation
55 yo HIV+ M BIB family members to ED for worsening generalized weakness x 1 month
Last seen in Owen Clinic several months PTA. At that time off meds for 2 years. CD4 was 205/9% and VL 800,268 c/mL
Poor historian, vague responses
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ROS
+ chills and sweats, nausea, anorexia, weight loss, dizziness, and abdominal pain
- confusion, headaches, neck pain, cough, sob, chest pain, diarrhea, dysuria, diarrhea or myalgias
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Past Medical History
HIV ‘01 Pulmonary TB ‘01 (treated x 9 months) Cryptococcal Meningitis ‘07 Neurosyphilis ‘08 T2DM ’08: mild, diet controlled CAP ‘09 Hypogonadism GERD
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More History
Meds (prescribed but not taking): Kaletra, truvada, mepron, androgel, zantac, gabapentin, vicodin
Allergies: bactrim -> rash ScHx: dentist, lives mostly in
Mexico, bisexual, divorced from wife, no children, + 35 pack year tobacco history, history of etoh and meth abuse
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Physical Exam (ED): Gen: wd/wn Hispanic M, lying in bed, lethargic and
slow to respond, slightly confused, shivering VS: T 91.5 F, BP 93/63, HR 70, R 18, O2Sat: 99%
RA H: NCAT, PERRL, O/P clear, MMM N: supple, no lad CV: RRR, nl s1,2, no m,r,g L: CTAB A: nabs, soft, nontender, no masses E: no edema N: A&O X3, CNs intact, nl motor and sensory
exams, brisk DTRs S: intact
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Test Results
Chem: Na 130, K 3.5, Cl 98, HCO3 23, BUN 26, Cr 1.91, G 152, Ca 8.5, A 3.6, LFTs: NL, CPK 115, TSH 5.53, Cortisol 29.6, lactate 5, CBC: WBC 5.0 (82%N), H 12.0, Plt 167K
INR 1.2, PTT 37.7 UA: 1+ PRT, WBC 0-2, RBC none Tox: BAL<10, + amphetamines CSF: nl OP, WBC 1, RBC 131, TP
33, G 55, II neg, GS neg
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Other study results
ECG: NSR, prolonged QT interval (487ms)
CXR: moderate interstitial pulmonary edema pattern
KUB: nonspecific bowel gas pattern, no evidence of obstruction
CT H (noncontrast): cerebellar and cerebral volume loss greater than expected for age but no acute fracture or evidence of acute hemorrhage, midline shift, or mass effect; no interval change from April ’08 CT
CT A/P (IV contrast): unremarkable
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ED course
Management: bair hugger, warmed IVF, stress dose steroids, IV Abx and admit to medicine
Initially worsened; T 90.0oF and BP 81/57. ICU team called but a few hours later T 93.3oF and BP 100/76
Housestaff added clindamycin and primaquine for PJP coverage and tamiflu for influenza coverage. Isolated and active rewarming continued
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Hospital Day #2
Tmax 103.3, 4 cm x 4 cm R supraclavicular indurated and nontender mass first noted
HNS consulted Recommended CT neck and chest
and FNA of LN
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Hospital Days #3 and 4
Daily fevers CT N (w/ contrast): necrotic and enlarged
lymph nodes in R SC area and R upper mediastinum
CT C (w/ contrast): miliary pattern of lung nodules
Labs: Cr 0.86, Influenza A, B negative, Blood cultures x 4 NG (x one + CNS), CRAG neg, Cocci CF/ID neg, U histo Ag neg, Aspergillus Galactomannan neg, U Legionella neg, CMV DNA PCR neg, RPR 1:8 (down from 1:16), QFT negative, CD4 = 25/10%, VL 195,976, CSF: HSV PCR, VDRL negative
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Hospital Day #5
T max 104.3oF HNS: flexible nasopharyngo-
laryngocscopy negative for lesions and FNA of R SC LNs done
FNA path: suggestive of granulomas RIPE + A started for TB and MAI
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LN FNA – 20x
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Hospital Day # 6
Feeling better FNA studies including flow
cytometry and AFB smear negative ENT reconsulted for more LN tissue Sputum AFB smears x 3 negative
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LN Core Bx: H&E 10X
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LN Core Bx- H&E 20X
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LN Core Bx - AFB 60X
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Hospital Day #7
Afebrile x 48 hours, discharged (after consultation with DPH) on RIPE + A (DOT), dapsone and outpatient f/up
One month later AFB cultures from sputum, FNA and blood grew M. Tuberculosis
Conclusion: hypothermia was due to M. TB sepsis (Landouzy sepsis)
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Temperature Curve
TB therapy started
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Hypothermia
Definition Pathophysiology Causes Clinical Manifestations Laboratory Evaluation Management
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Definition and Classification Core Temperature <35oC (<95oF) Mild: 32-25oC (90-95oF) Moderate: 28-32oC (82-90oF) Severe: <28oC (<82oF)
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Pathophysiology
Body temperature balance between heat production and loss Heat generated by cellular metabolism
(mostly in heart and liver) Heat lost by skin and lungs via:
Evaporation Radiation Conduction Convection
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Pathophysiology - 2
Body’s response:
Hypothalamus (increase heat production)
Shivering
Stimulation of thyroid, catecholamine and adrenal activity
Sympathetic nervous system (decrease heat loss)
Vasoconstriction; reduces blood flow to peripheral tissues
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Causes
Increased heat loss: Environmental exposure Induced vasodilation (eg, medications,
etoh, toxins) Skin Disorders (eg, burns, psoriasis,
exfoliative dermatitis) Iatrogenic (eg, cold infusion,
emergency deliveries, cardiopulmonary bypass, CRRT)
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Causes
Decreased Heat Production Endocrinologic Failure (eg,
hypopituitarism, hypoadrenalism, hypothyroidism)
Insufficient Fuel (eg, hypoglycemia, malnutrition)
Neuromuscular inefficiency (eg, extremes of age, impaired shivering, inactivity)
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Causes
Impaired Thermoregulation Peripheral (eg, spinal cord transection,
neuropathies, diabetes mellitus) Central (eg, CVA, SAH, Parkinsonism,
hypothalamic dysfunction, MS, anorexia, drugs including anxiolytics, antidepressants, antimanic agents, antipsychotics, opioids, antihyperglycemics, beta blockers)
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Other Causes
Sepsis Pancreatitis Carcinomatosis Uremia Vascular Insufficiency Trauma
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Hypothermia and Tuberculosis
4 cases reported in the literature All associated with meningitis 3 also associated with hydrocephalus 2 reversed after placement of ventricular
shunt 2 cases thought related to pressure on
hypothalamus and one due to vascular lesion in hypothalamus
No case like this one (hypothermia in TB without meningeal involvement) found in literature
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Clinical Presentation
Mild: tachypnea, tachycardia, ataxia, dysarthria, confusion, shivering
Moderate: hypoventilation, progressive bradycardia, hypotension, atrial and ventricular arrhythmias, CNS depression, loss of shivering,
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Clinical Presentation
Severe: pulmonary edema, apnea, worsening bradycardia and hypotension, ventricular fibrillation (<28 C) and asytole (<20 C), coma, muscle rigidity
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Laboratory Findings
ABG: metabolic acidosis, respiratory alkalosis, or both
Lytes: no consistent abnormalities Glucose: increased, decreased or normal WBC and Platelets: decreased due to
splenic sequestration Hemoglobin: increased due to
hemoconcentration
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Other Studies Lipase: may be increased due to
hypothermia induced pancreatitis PT/PTT: increased in vivo due to inhibition of
coagulation cascade, despite normal reported values
ECG: prolongation of PR, QRS, QT intervals, ST segment elevation, T wave inversions, Osborn J waves, atrial fibrillation or sinus bradycardia
CXR: aspiration pna, vascular congestion, pulmonary edema
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J (Osborn) Wave
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Management
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Management
Intubate obtunded patients and those with bronchorrhea
Treat hypotension with warmed (42oC) NS, dopamine if necessary
Avoid rough movements and activity which may induce ventricular fibrillation
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Rewarming Strategies
Mild Passive external rewarming (blankets)
Moderate Above + active external rewarming (forced
warm air applied to skin via Bair Hugger blankets)
Severe Above + active internal (core) rewarming
warm IVF (40-42oC) warmed humidified O2
irrigation of body cavities with warmed crystalloid extracorporeal blood rewarming (eg hemodialysis)