Transcript NYU Medical Grand Rounds Clinical Vignette

NYU Medical Grand Rounds
Clinical Vignette
Mark H. Adelman, M.D.
PGY-2
2/19/13
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 43 year old man presents with headache,
neck pain for approximately one week
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Diagnosed with HIV in 2002, on HAART
until he lost insurance in 2009
•Doing well until 10 days prior to admission,
felt like there was “fluid swishing in my ears”
•Four days later, vomited multiple times,
began to experience headache and neck
stiffness
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Presented to ER, head CT, left AMA prior to
complete evaluation
•Headache, neck stiffness, nausea/vomiting
continued
•No relief with naproxen, ibuprofen
•Returned to ER for unremitting headache
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•Bipolar II
•Past Surgical History:
•Hernia repair as a child
•Social History:
•No tobacco. Rare alcohol. Infrequent intranasal cocaine, semiweekly cannabis use
•Sex with men
•Family History:
•noncontributory
•Allergies:
•No known drug allergies
•Medications:
•Naproxen, ibuprofen as needed
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: Well appearing man, alert, in mild
distress
•Vital Signs: T: 97.5, BP: 125/78, HR: 55,
RR: 16, O2 sat: 96%RA
•Neck pain with flexion/extension
•Remainder of Physical Exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: Hemoglobin 16.7
•Remainder of CBC was within normal limits
•Basic metabolic panel: Potassium 3.5
•Remainder of basic was within normal limits
•Hepatic panel: ALT 74
•Remainder of hepatic panel was within normal
limits
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CSF
•Opening pressure 37
•12 WBCs (84% lymphocytes, 16% monocytes)
•Protein 64
•India ink, culture, cryptococcal antigen, HSV PCR
pending
•Blood cultures: pending
•CD4 count and HIV-1 RNA: pending
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
•Chest X-Ray: 1cm nodular opacity in right
midlung
•CT head: no acute intracranial findings
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working or Differential Diagnosis
• Cryptococcal meningitis
• Viral meningitis
• HSV encephalitis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
• Amphotericin, flucytosine. Acyclovir
• Hospital Day 2:
• CD4 count 52 (5%). HIV-1 RNA 28,400.
• Trimethoprim-sulfamethoxazole
• Repeat lumbar puncture
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 3:
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CSF India ink stain + for cryptococcus
CSF cryptococcal antigen + (1:8,192)
Serum cryptococcal antigen + (1:32,768)
CT chest: Multiple round, nodular opacities
right lower lobe. Mediastinal, pretracheal, right
hilar lymphadenopathy
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 4:
• Headache improved
• HSV PCR negative. Acyclovir discontinued
• HD#1 CSF fungal culture + for cryptococcus
• Hospital Days 5-7
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•
•
•
Induced sputum negative for AFB x3
HD#2 CSF fungal culture + for cryptococcus
Blood cultures + for cryptococcus
Bronchoscopy: BAL, transbronchial lymph node/lung
biopsies negative for AFB, + for cryptococcus
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 8:
• Repeat LP: opening pressure 36
• Cryptococcal antigen 1:512. Culture negative. VDRL +
• IV penicillin G
• Hospital days 9-14
• Recurrent headaches
• serial LPs until opening pressure 20. Cultures negative
• Right occipital lymphadenopathy
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 15
• Amphotericin, flucytosine discontinued
• Oral fluconazole started
• Hospital Day 16
• Fine needle aspiration of occipital lymph node
• Hospital Day 18
• IV penicillin discontinued
• FNA + for cryptococcus
• Discharged home with virology follow-up in one week
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Disseminated cryptococcosis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS