Transcript ID Case Conference 10-10-07

Hemoptysis Mentioned in
the Review of Systems…
Gretchen Shaughnessy, MD
Clinical Fellow
Dept of Infectious Diseases
CC: Cough, weight loss
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45-year-old woman referred for new
diagnosis of HIV. She states she started
feeling sick about a year ago and noticed
weight loss and night sweats. She has lost
about 30 lbs over the past year and in
August 2007 developed a cough productive
of yellow sputum with fevers and chills. She
got levofloxacin from a local family physician
which improved her symptoms but she
continued to have a mild cough.
HPI (cont)
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When she went to the doctor in August it
was the first time she had sought medical
are in the past 10 years.
Cough worsened and she was diagnosed
with pneumonia again in December 2007.
Improved with levofloxacin again, but at her
follow up visit she was found to have
thrush.
An HIV test was done that was positive and
she was referred to UNC ID Clinic.
ROS
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Positive for cough and night sweats. The
patient states that her cough is currently
productive of white sputum and for the past
few weeks it has been streaked with blood.
She states that each time she has gotten
antibiotics she improved but she has never
completely gotten rid of her cough. Review
of systems is otherwise negative.
PMH
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G2P2
She has never been hospitalized and
does not have any chronic medical
problems other than the HIV.
Allergies/Medications
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Allergies – NKDA
Fluconazole 100mg po daily
Recently completed 7 day course of
Levofloxacin 500mg po daily
Social History
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Works at a mall
Lives in Durham, no recent travel.
She has 2 children ages 21. 25, and 3
grandchildren neither her children nor
grandchildren live in the house.
She previously smoked 1 pack a day since she was
a teenager but quit one month ago.
Occasional alcohol
The patient denies any contact with tuberculosis.
She has 1 dog who lives outside.
Social History (cont)
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She has never been homeless and
never been in prison.
The father of her 21-year-old daughter
died of AIDS in the early 90s. After
she heard about his death, she
considered getting an HIV test but did
not because of fear.
History (cont)
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Sexual History - Sexually active since the
age of 16. Approximately 10 lifetime sexual
partners, only her current husband for the
last 10 years. He is aware of her diagnosis
and is awaiting HIV test results. She has no
history of trading sex for drugs or sex for
money, no history of other STIs.
Family History – Father died age 59 from
MI. Mother died young in accident.
Physical Exam
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T 37, BP 136/92 P 115 R 18 O2 sat 99% on room air
INAD, marked anxiety, temporal wasting
EOMI, PERRLA. Nonicteric sclerae.
Thrush Present, upper palate dentures. <1cm area of increased
pigmentation on L tongue
Shoddy cervical LAD, all <1cm in diameter. No supraclavicular,
axillary or inguinal lymph nodes.
RRR, no m/r/g
CTAB, No wheezes, rhonchi, or rales on my initial exam.
Soft, nontender. No hepatosplenomegaly, no masses
No clubbing, cyanosis or edema.
No rash or skin lesions.
No neurologic abnormalities.
Labs
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CD4 62, 8%
VL 507,000
CBC – 3.7>9.6/29.0<497
Diff – 2.6-0.7-0.2-0.1-0.0
PCP DFA neg
U/A, UCx, neg
Radiology
Radiology (cont)
Further Diagnostic Tests
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Sputum 3+ AFB on smear
TB-PCR negative x 2
OSSA on bacterial sputum culture
Sequencing of growth from AFB culture revealed
Actinomyces sp confirmed with repeat sequencing.
Evaluation for background MTB was negative.
Actinomyces sp.
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gram-positive filamentous
bacteria
Order of Actinomycetales,
family Actinomycetaceae,
genus Actinomyces.
Grow slowly in anaerobic-tomicroaerophilic conditions,
colonies with a molar tooth
appearance. The most
commonly isolated species is
Actinomyces israeli
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Sulfa granules
Not usually acid fast, but one
case report from 1980 when
using Putt stain
eMedicine 2008
http://www.bact.wisc.edu/themicrobialworld/dental.html
Cervicofacial actinomycosis
(ie, lumpy jaw)
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History of dental manipulation or
trauma to the mouth, poor oral
hygiene, dental caries, or
periodontal disease
Painless or occasionally painful
soft-tissue swelling involving the
submandibular or perimandibular
region; over time, multiple
sinuses drain pus containing
sulfur granules; tendency to remit
and recur
Reddish or bluish discoloration of
the skin overlying the lesion
Chewing difficulties (ie, with
involvement of mastication
muscles)
eMedicine 2008
NLM 2008
Thoracic Actinomycosis
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Thoracic actinomycosis
– History of aspiration (Risk factors include
seizure disorder, alcoholisms, and poor
dental hygiene.)
– Dry or productive cough, occasionally
blood-streaked sputum, shortness of
breath, chest pain
– Fever, weight loss, fatigue, anorexia
Abdominal actinomycosis
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History of abdominal surgery, perforated viscus,
mesenteric vascular insufficiency, or ingestion of
foreign bodies (eg, fish or chicken bones)
Nonspecific symptoms
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Low-grade fever
Weight loss
Fatigue
Change in bowel habits
Vague abdominal discomfort
Nausea
Vomiting
Sensation of a mass
eMedicine 2008
Pelvic actinomycosis
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History of IUCD
Lower abdominal
discomfort,
abnormal vaginal
bleeding or
discharge
HIV and Actinomyces
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Cervical-facial Actinomycosis in AIDS
patients reported in 1986
Endobronchial actinomycosis in an HIV
patient first reported in Chest in 1993
A rare condition in AIDS patients.
– Possibly because of empiric antibiotic
use?
References
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Lowe RN, Azimi PH, McQuitty J. Acid-fast
actinomyces in a child with pulmonary
actinomycosis. J Clin Microbiol. 1980
Jul;12(1):124-6.
Takiguchi Y, Terano T, Hirai A. Lung abscess caused
by Actinomyces odontolyticus. Intern Med. 2003
Aug;42(8):723-5.
Chaudhry SI, Greenspan JS. Actinomycosis in HIV
infection: a review of a rare complication. Int J STD
AIDS. 2000 Jun;11(6):349-55.
Ossorio MA, Fields CL, Byrd RP Jr, Roy TM. Thoracic
actinomycosis and human immunodeficiency virus
infection. South Med J. 1997 Nov;90(11):1136-8.