LSU MEDICINE CASE

CONFERENCE

David Klibert ,MD

Internal medicine, HO II

August 21st, 2012

CHIEF COMPLAINT

Brought in by family for acute confusion

HPI

A 30 year old man with past medical history of HIV diagnosed in 2003, with a CD4 of 30(4/12) presented to the ED with right sided chest pain work up revealed a Rt upper lobe bleb which was thought to be stable from previous imaging and since the patient had no other complains with stable vital signs,hispain was thought to be musculosketletal as per ED physician and was discharged home with a HOP clinic follow up.

4 days later the patient was brought in by the family for altered behavior. In the ED the patient was confused ,he could tell his name but not the year or the day. He was also confused as to why he was brought to the ED. He intermittently answered questions appropriately.

HISTORY

Past Medical Hx HIV: diagnosed 2003, last CD4 count 30 viral load 412

thousand (4/12)

Followed by HOP clinic since 2006, , last seen in 2010

On HAART therapy since 11/2006 with intermittent compliance

History of resistant genotype

Varicella zoster, 2006

Asthma

GERD

Past Surgical Hx: Unknown

Allergies: NKDA

Home Meds – noncompliant since 2011 Norvir 100 mg PO daily

Reyataz 300 mg PO daily

Truvada 200/300 mg PO daily

Bactrim DS PO daily

HISTORY

SocHx:

Lives with aunt in New Orleans and is

unemployed

Reports 3 pack year history of tobacco,

6 pack beer daily with liquor on weekends

Denies IVDU or cocaine, FamHx: Unknown

HM: Influenza 2009, pneumavax 2010, td 2008,

Hep B vaccine 2008, PPD 2008 NR, RPR 2009

NR

ROS

ADMITS TO

Bilateral shoulder pain

Couldn’t characterize the severity ,duration or

type of pain

Headaches

Subjective fever, chills

Non productive cough

VITAL SIGNS

TRIAGE :

Temp 97.3

HR 54

BP 120/83

RR 16

O2 sats 100% RA

HT 5 feet 6 inches

WT 126 pounds

BMI 20

OnExam:

Temp 98

HR 58

BP 120/77

RR 20

O2 sats 100% RA

PHYSICAL EXAM

Gen: AAOX1 to person only ; not to place or time.

Able to intermittently answer questions appropriately

HEENT: PERRLA, EOMI

No scleral or sublingual icterus

Orpopharynx clear with no thrush,poor dentition. TM clear

Visual acuity 20/30 OD, 20/20 OS, VF normal

Fundoscopy (un dilated eyes)-No papilledema

No neck mass or LAD

CVS: RRR, no murmurs, normal S1, S2

Resp: CTA bilaterally, no crackles, wheeze.

Abd: Soft, nontender, nondistended, bowel sounds present

Ext: no edema, 2+ distal pulses

PHYSICAL EXAM ….(PLEASE REFINE YOUR

NEURO EXAM JUST WRITE AS PER MAXWELL

BOOK-NEEDS TO BE RE WRITTEN

Neuro: Limited by participation.

JUST MENTION CRANIAL NERVES INTACT

Motor: 4/5 B/L Upper and Lower Extremeties

Sensory: 2+ DTR. Sensations intact

Difficulty with finger to nose bilaterally

R>L. Normal rapid alternating movements. Neg

rhomberg. Speech normal rate, volume and tone.

No dysarthria. Intermittently answers questions

appropriately. Unable to answer basic questions

such as name, location, recent events.

Skin: scar L back below scapula, otherwise no

rash, lesions

LABS

Seg 62

Band 9

Lymph 11

Mono 14

Eos 2

Baso 1

77.313.6

38.73.2 195

27.1

134

3.1

98

26

8

0.89169

9.4Mg 2.3

Phos 3.4

ER Serum Tox: negative

Urine Tox: + THC, + cocaine

TSH: 0.64

Lactic acid: 1.7

LDH: 222

UA: 1.011, urobili 1.0

CD4 count: 30

Viral Load: 121217

Genotype: no mut

RPR: NR

10/2003 Toxo IgG reactive

IgM negative

TP Alb Bil AST ALT ALP

8.3 0.64.3 41 25 45

CHEST XRAY

CT HEAD

I am assuming ya’ll didn’t do an LP secondary to

increased ICP….

HOSPITAL COURSE

After reviewing the CT scan ,Neurosurgery

consulted; recommended close monitoring in ICU

Ceftriaxone and Ampicillin for empiric bacterial

meningitis coverage in the ED

Dexamethasone to reduce cerebral edema.

Acyclovir for empiric HSV coverage.

MRI ordered for further evaluation

HAART therapy held to prevent IRIS

PJP and MAC prophylaxis with Trimethorim-

sulphamethoxazole and Azithromycin initiated

respectively

MRI OF THE HEAD

HOSPITAL COURSE CONTINUED…

PET scan done given MRI report in favor of

primary or secondary lymphoma versus

metastasis; however it did not show any

evidence of Malignancy/Lymphoma

Therefore a frontal lobe brain biopsy was

performed by Neurosurgery on day #8

The post operative course was complicated by

hyponatremia due to SIADH ;the patient became

even more combative and confused requiring

treatment with demecocycline and 3% Hypertonic

saline

BRAIN BIOPSY

Toxoplasma oocytes with surrounding gliosis (10 X)

Toxoplasma oocyst with encysted toxoplasma bradyzoites (40x)

Anti-toxoplasma immunohistochemistry highlighting the toxoplasma oocyst

Anti-toxoplasma immunohistochemistry highlighting the toxoplasma oocyst (60x)

DIAGNOSIS :

CNS

TOXOPLASMOSIS

HOSPITAL COURSE CONTINUED…

The patient gradually continued to improve

and was discharged on day#23 –

Pyrimethamine 25 mg 2 tablets daily

Sulfadiazine 1 g p.o. every 6 hours

Leucovorin 25 mg daily

Zithromax 1200 p.o. q.week

Trimethoprim-sulfamethaxozole daily

Dexamethasone taper

Phenytoin sodium100mg TID

Fludrocortisone 0.1 mg daily

For 6 weeks

total

FOLLOW UP

The patient was seen in the HOP clinic the day

after discharge and was started on HAART

therapy with

Isentress 400 mg PO BID

Truvada 200-300 mg PO daily

Was last seen in ED a week after discharge for

apthous ulcers and has not been to HOP clinic in

the last 3 months.

THANK

YOU

HOSPITAL COURSE

Day 1:.. Family confirmed patient baseline mental status 1-2 weeks prior to presentation. HAART held to prevent IRIS.

Day 2: De-escalate HSV and bacterial coverage. CT chest and abd to look for primary malignancy. Started seizure ppx with keppra. Step down to medicine.

Day 5: PET scan not suggestive of lymphoma. Began to develop euvolemic hyponatremia with low serum Osm, high urine Osm and high urine sodium.

Day 8: Open frontal brain biopsy. Monitored in TICU. Started on 3% NS and demeclocycline for hyponatremiasecondary to SIADH. Seizure ppx changed to fosphenytoin.

Day 10: Path results confirm Toxoplasmosis

Day 15: Step down to medicine.

Day 18: Initial AFB sputum culture positive. AFB smear negx 3 and T spot negative on admission. Started on tolvaptan

Day 21: Repeat AFB smears negative.

Day 23: Discharged to home.