KLINIK UND POLIKLINIK FÜR INNERE MEDIZIN I Fakultät für Medizin Opportunistic Infections Diagnosis & Management Cases Cases B. Salzberger UKR MEDIZIN I UNIVERSITÄT REGENSBURG OIs in HIV-Infection • Ois are still frequent – even in the developped world • In Europe, about 50% of HIV-infected patients present late (<350 CD4 at first visit) or very late present late (<350 CD4 at first visit) or very late (<200 CD4 at first visit) • Ois first presentation or complication of ART initiation (IRIS) • Relatively strict correlation between CD4-cells and OIs –except for Tb UKR MEDIZIN I UNIVERSITÄT REGENSBURG CD4 cell count and OIs Years UKR MEDIZIN I UNIVERSITÄT REGENSBURG OIs by organ system • Pulmonary – Pneumocystis pneumonia; recurrent pneumococcal pneumonia, tb, fungal infections (rare in Europe) • GI • GI • CNS – Cryptococcosis, Toxoplasmosis, Cysticercosis, PML, CMV retinitis and encephalitis • Disseminated – Salmonella sepsis, atypical mycobacteriosis Research Centre for Health Economics and Evaluation (ReCHEE)
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• Ois are still frequent – even in the developped world
• In Europe, about 50% of HIV-infected patients present late (<350 CD4 at first visit) or very late present late (<350 CD4 at first visit) or very late (<200 CD4 at first visit)
• Ois first presentation or complication of ART initiation (IRIS)
• Relatively strict correlation between CD4-cells and OIs –except for Tb
Research Centre for Health Economics and Evaluation (ReCHEE)
UKR MEDIZIN I UNIVERSITÄT REGENSBURG
One View Quiz
• Minor manifestations – not to be missed
• Opportunity for diagnosis of HIV..
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Research Centre for Health Economics and Evaluation (ReCHEE)
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Case I
• 35yo male, weight loss of 2kgs over 4 weeks, dry cough for three weeks, increasing in frequency and severity. Shortness of breath with exercise, not able to workexercise, not able to work
• Physical exam: – Underweight male (BMI 18), oral thrush, no skin rash,
• What can you do to ascertain your clinical diagnosis?– Testing before treatment?
• Empirical therapy?• Empirical therapy?
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Diagnostic workup
• Bronchoscopy with cytology– Giemsa stain
– Immunofluorescence
– PCR– PCR
• Throat gargle– PCR
• PCR very sensitive! Caution in cases without clear clinical findings
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What happened to our patient?
• Empirical treatment started with Cotrimoxazole and steroids
• PcP diagnosed with bronchoscopy
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Further clinical course
• Lab exam: CD4 cell count 110 (6%)
• Respiratory failure, intubation for 6d
• Rapid recovery, started on tenofovir, emtricitabin, efavirenz day 14emtricitabin, efavirenz day 14
• Discharged day 28 on ART and PcP-prophylaxis
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PjP Grocott Stain
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Case II
• 26yo female
• HIV-infection diagnosed in pregnancy two years earlier, premature delivery at week 18, no clinical follow upclinical follow up
• Severe headache for 2 weeks, blurred vision in last two days, fever and weight loss
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Case II: Clinical presentation
• Acutely ill, lethargic, BMI 16, HR 72, respir. Rate 22, Temp. 38.5 C. No shortness of breath, cardiac and pulmonary exam without findings, multiple cervical, axillary and inguinal multiple cervical, axillary and inguinal lymphnodes up to 1,5 cm, spleen palpable, slightly enlarged
• Neurologic exam: neck supple, no meningeal signs, no focal neurologic deficits
• Workup?
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Do we need a CT-scan?
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Do we need a CT-scan?
I agree, but why?
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• Ulcerative, necrotizing inflammations of large bowel, gastro-esophageal region, stomach, small bowel, e.g. causing bloody diarrhea or dysphagia
• 2nd most common manifestation in SC-/BM-transplant • 2nd most common manifestation in SC-/BM-transplant patients, in HIV-infected patients and in solid organ transplant patients
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CMV-Retinitis
• Most common manifestation in HIV-infected patients, rare in SC-/BM- and solid organ transplant patients
• diffuse necrosis and bleeding, causing rapid loss of vision
• treated with iv GCV, oral VCV or topic GCV• treated with iv GCV, oral VCV or topic GCV
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Diagnosis of pathogen?
• Serology not helpful – IgM might be present with reactivation, correlation is quite bac
• systemic replication present in 50% of patients early in the diseaseearly in the disease– pp65-Antigen can be demonstrated on leukocytes
– DNA-PCR has same sensitivity and specifity, easier in large volumes
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Case III: pp65 Antigen
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CMV viremia as a prognostic marker
Durier , CID 2013
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Case III: therapy
• Ganciclovir iv 2x5mg/kg/d or Valganciclovir 900mg/d po for 3 weeks
• Continue maintenance with half dose until CD4> 100 with ART100 with ART