Transcript Journal Club - NYU Langone Medical Center

NYU Medical Grand Rounds
Clinical Vignette
Sunnie Kim, MD
PGY3
Tuesday, May 29, 2012
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
•The patient is a 25 year-old man who
presents for follow-up for chronic leukopenia
and requesting HIV testing and counseling,
as well as information about pre-exposure
prophylaxis.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•History of multiple male sexual partners.
•Six months prior to presentation was evaluated
after a high-risk sexual contact with condom
malfunction and penile laceration.
•Treated with 28-day course of zidovudine,
tenofovir and lamivudine for post-exposure
prophylaxis.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Also evaluated and treated for chronic facial
acne vulgaris in dermatology clinic.
•Having failed topical antibiotics and
antimicrobials, was initiated on isotretinoin.
•During this time, he was noted to have
persistent leukopenia and was referred to
medicine clinic.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•The patient also requests HIV testing, and
counseling on means of prevention,
including medications or vaccines.
•He reports several HIV-negative friends on
chronic anti-retroviral therapy for HIV
prevention.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical and Surgical History
•None
•Social History:
•Multiple concurrent male sexual partners
•Inconsistent condom use
•No known history of sexually transmitted infections
•Occasional MDMA/ecstasy use
•Occasional alcohol use with intermittent binge drinking
•Family History:
•none
•Allergies:
•NKDA
•Medications:
•Isotretinoin 20mg bid
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•Well appearing.
•Vitals: T97.8F, BP 106/62, HR 61, RR 16
•Numerous hyperpigmented macules and
atrophic scars over the face and upper back.
•Otherwise normal examination
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Prior Laboratory Findings
•CBC:
•WBC 3.1 (N 59%, L 34%, Eos 6%, Baso 1%)
•Hg 14.1g/dl
•Platelets 182,000
•Cr 0.9mg/dl
•AST 41mg/dl (11-39)
•ALT 45mg/dl (11-35)
•The remainder of the hepatic panel and basic
metabolic panel was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
Mildly elevated transaminases with leukopenia
- chronic viral infection
- iatrogenic from chronic acne treatment
(antimicrobials or isotretinoin)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• The patient received counseling on safe sex practices
including consistent condom use.
• No HIV vaccine is currently available for clinical use.
• Pre-exposure prophylaxis was not initially offered to the
patient due to limited evidence and interim CDC
guidelines.
• Scheduled for follow-up visit for further counseling.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• The patient screened negative for HIV,
hepatitis B and C, gonorrhea, and
chlamydia infections.
• Repeat CBC showed stable WBC (3.1-5.0)
• Transaminases normalized after
completion of isotretinoin treatment.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
Otherwise healthy man engaging in high-risk
sexual activities despite counseling.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS