Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Matthew B. Brown M.D. PGY-2
10/4/11
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• The patient is a 50 year old man
presenting to Bellevue clinic, complaining of
unintentional weight loss, fatigue and
malaise for the past year.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• The patient was diagnosed with HIV at an
outside clinic in 1989; He never received
treatment with ART.
• One year ago, he experienced the onset of
progressively worsening weight loss and
fatigue.
• During this time, he was treated for
recurrent skin infections and soft tissue
abscesses.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
• Past Medical History:
• Shingles, Thrush (2009)
• Past Surgical History:
• No history of surgery
• Social History:
• Pt. denies any history of ETOH or tobacco use
• High school teacher; lives in Brooklyn with family
• Remote unprotected sex with men and women
• Currently monogamous with his wife, uses protection
• Family History:
• No pertinent family history
• Allergies:
• No known drug allergies
• Medications:
• No medications
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
• General: Thin-looking middle aged male,
comfortable appearing
• Vital Signs: T: 98.0 BP: 108/65 HR: 90 RR:
16 and O2 sat: 100% RA
• Exam notable for mild thrush on the surface
of the tongue, as well as scattered, small
axillary lymphadenopathy L > R, non-tender
• Remainder of Physical Exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
• CBC: WBC 5.1 10^9/L , Hgb 10.6 g/dL (1418), Plts 287 10^9/L, MCV 89.9 Fl
• Basic Metabolic Panel: BUN 16 mg/dL, Cr 1.0
mg/dL, normal electrolytes
• Total Protein 9.1 g/dL (6.4-8.2), Albumin 3.9
g/dL (3.5-5.3), otherwise normal Hepatic Panel
• CD4 Count, HIV Viral PCR, HIV Genotype
were also ordered
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Initial Visit Tests
• Patient screened for the following:
• Syphilis (RPR) -> negative
• TB (Serum Quantiferon) -> negative
• GC/Chlamydia (Urine DNA) -> negative
• Hepatitis B (serum Ag, Ab) -> immune
• Hepatitis C (serum Antibody) -> negative
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
• At the time of his initial clinic visit, the
patient was diagnosed presumptively with
AIDS (CD<200), WHO Clinical Stage III
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course (Initial Visit)
• The patient was started on Bactrim for
PCP prophylaxis
• Additionally, he was prescribed a 14 day
course of Fluconazole to treat his thrush
• He was offered Influenza, Pneumonia,
Tdap, and HBV Vaccinations
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course (Second Visit)
•
•
•
•
Diagnosis of AIDS confirmed
CD4 Count: 86 (14%)
HIV Viral Load: >100,000 copies/ml
HIV Viral Genotype: Wild Type (RT:
R211G), (PR: L63P, I64V, V77I)
• Patient’s thrush had resolved after
completing course of Fluconazole
• Patient initiated on ART with Atripla
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course (Subsequent Visits)
• The patient tolerated Atripla well with
minimal side effects
• Within one month, CD4 331 (22%); VL
<500
• By July 2011 (4 months after initiation of
ART), CD4 429 (25%); VL <50
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis/Summation
• HIV/AIDS and oral candidiasis, with
reconstituted CD4 and undetectable viral
load after initiation of HAART.
• The patient continues to follow closely in
the Bellevue virology clinic.
• He has gained back more than ten pounds
of his weight loss, has returned to his
teaching job and continues to do well.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS