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The Fever, a monologue written and realized by my beloved uncle Wallace Shawn, opened this week at the Acorn Theater in midtown Manhattan. Scott Elliott, the dramatic mastermind behind last year´s HurlyBurly, is directing the production for the New Group.

Whatever you do, do not believe the review today in the New York Times (which I will NOT link here), which includes some ridiculous drivel about the play running on too long. I have not seen the current production, but the two other times I have seen Wally do the play, they were not a second too long nor a second too short. They were perfect.

All of Wally´s plays are thought-provoking. This is one of the reasons I like them. The Fever is one of my absolute favorites. Granted, it can be difficult to accept some of the ugly thoughts and feelings that the play evokes, but that´s the point, dummy. The play addresses topics I think about constantly, including the discomfort that (relatively) rich visitors feel when travelling in (relatively) poor countries. But enough of my commentary--go see the play yourself. Wish I could be there too.

Case Record Continued...

Case Discussion: A 28 year old man with cough and fever, two weeks after starting Antiretroviral Therapy.

Sorry to Rafa and the other bored-by-medicine folk, but the comments on this case are really too good to leave hidden in the comments section of that last post. For those who missed them, Doctora Lola (Pulmonary Critical Care Specialist and ICU Director at one of NYC´s largest medical centers) said:

The differential is broad, although several elements of the history stand out to me as important; first he had 3 negative smears for AFB upon his initial diagnosis, second he had presumably been taking is PCP prophylaxis, third, he does not sound acutely ill on presentation to the MSF clinic, and lastly his symptoms began a couple weeks after the initiation of antiretroviral therapy. His CXR is certainly abnormal, with lower lobe predominant bilateral interstitial and micronodular infiltrates (one could use the ubiquitous radiologists term "reticulonodular infiltrates"). While the image quality is not perfect, he doesn't appear to have significant lymphadenopathy on the film. This radiographic pattern in an HIV patient is non-specific and could be many things, both infectious and non-infectious. Given his clinical course, infectious causes seem most likely, particularly with a possible element of immune reconstitution with him recently starting HIV meds. The infections I think are most likely are 1. PCP (despite prophylaxis), 2. TB, 3. Community acquired pneumonia 4. MAI (CD4 is a little high). Non-infectious etilogies to consider (although much less likely) are lymphocytic interstitial pneumonia, hypersensitivity pneumonitis and drug reaction.

Doctora Magda (Infectious Disease Consultant and HIV Researcher at another NYC mega-medical center) said:

I agree with Lola and think that IRIS is a real possibility, although his initial CD4 cell count was fairly high at 160. The risk of immune reconstitution increases with lower CD4 cell counts at the time of ART initiation. Of course, there are never any absolutes. I was curous whether you rechecked his eosinophils at his second presentation - I would also add strongyloides (hyperinfestation) to his ddx

Amazingly, the Puerto Barrios Community doc had arrived at the same differential diagnosis as the New York academic specialists! [Perhaps not all that amazing afterall, as I learned almost everything I know from these two bad-asses.)

I thought that infectious etiology was most likely, given the patient´s low grade fever and cough, along with the CXR results. The reticulonodular pattern on CXR was most suggestive of PCP, and the patient´s CD4 count of 160 would be consistent with this diagnosis. However, the pateint insisted that he had been taking his Trimethroprim, and I believed him. This would make PCP much less likely. Even though the patient had been AFB negative x 3 prior to starting his antiretrovirals, we all know that AFB smear is only about 50% sensitive in HIV positive patients with TB. I thought the likelihood of immune-reconstitution syndrome (IRS) with recognition of a previously undiagnosed TB infection was a real possibility. Of course Dr. Magda´s comment that IRIS is most commonly seen in patients with very low CD4 counts crossed my mind, making this diagnosis a bit less likely in our patient with CD4 of 160. I did not think about strongoloides hyperinfection. It is a great thought though, because we see a lot of strongoloides here (stool smears for parasites are one of the few strengths of our lab here in PB), and immunosuppresed patients are at high risk for hyperinfection.

So what is Immune Reconstitution (IRIS) anyway? I am no expert. My understanding is basically that as AIDS patients replenish their CD4 counts and their immune systems recover, the T-cells start fighting infectious that they previously did not have the energy to notice. A 2004 review in Clinical Infectious Diseases describes IRIS as:

an inflammatory syndrome occurring days to months after the start of ART, with outcomes ranging from minimal morbidity to fatal progression. This syndrome can be elicited by infectious and noninfectious antigens. Microbiologically, the possible pathogenic pathways involve recognition of antigens associated with ongoing infection or recognition of persisting antigens associated with past (nonreplicating) infection.

About 25-50% of IRIS cases are thought to be due to mycobacterial disease that was subclinical prior to starting antiretroviral therapy.

So what happened with the patient? I started him on empiric treatment for PCP as an outpatient and told him to drop off as many sputum samples as possible at the Centro De Salud for AFB analysis. He came back the next week with three samples +++ for AFB. I stopped the PCP treatment and told him to go back to the Centro de Salud STAT to get TB treatment. He is now on four drugs for tuberculosis and continues on Anti-retrovirals.

Thanks Lola and Magda! I miss you.

Case Records of the Hospital Nacional, Puerto Barrios

If any medical types are reading this:

Case Records of the Hospital Nacional, Puerto Barrios: A 28 year-old man With Cough and Fever, 2 Weeks After Starting Antiretroviral Medicine

Sr. L is a 28 year old man who lives in Eastern Guatemala. He was well until the fall of 2006, when he began to lose weight and feel weak. He also noted fevers and watery diarrhea. He did not have a cough. He went to a neighborhood doctor, who took blood for lab tests. Results of initial labs showed WBC 9,100 (55% PMS, 42% lymphs, 3% Eos), Hg 9, Hct 28, AST 64, ALT 63. A stool study was positive for Entamoeba Histolytica. Three sputum smears were negative for AFB. Rapid HIV test was positive. He was referred to the MSF clinic, Hospital Nacional, Puerto Barrios.

We saw him for the first time on Oct 9th. He recounted the history outlined above. He has no other past medical or surgical history. He takes no medicine. He has no known allergies. He lives with his wife, who is pregnant, and 7 year old son. He is currently unemployed; he used to work as a salesman. He used to drink beer every day, but stopped when he found out he was HIV positive (one week before he came to our clinic). He does not use drugs or smoke tobacco. Reviews of systems was otherwise unremarkable. His exam was notable for a young man who appeared thin, but not acutely ill. His weight was 43 kgs, height 158 cm (BMI 17), pulse 92 and he was breathing comfortably. His conjunctiva were pale pink and nailbeds pale: he had oral thrush. His thorax and cardiovascular, and abdominal exams were normal.

Our initial impression was a 28 year old man with AIDS (CDC stage B), anemia, mild transaminitis, and Entamoebia Histolytica. We ordered a CD4 count. Our lab cannot do any tests that are not listed above. We follow the Guatemalan National Protocol for TB screening (they do not screen for latent disease). We started him on 1 double strength TMP-SMX daily (PCP prophylaxis) and Metronidazole 500 mg q8 for 14 days (E. Histolytica treatment).

He returned for a follow-up visit three weeks later. He did not have any new complaints. His CD4 count came back at 160. He was seen by the social worker and psychologist, and was approved by the Committee for Anti-Retroviral therapy. In mid-December, we started him on Nevirapine, 3TC, and D4T. He continued Trimethroprim prophylaxis, and reported adherence to this therapy.

He returned two weeks after starting Antiretrovirals complaining of a productive cough, fever, and shortness of breath on exertion for 1 week. He denied diarrhea and other GI and cardiac symptoms. His weight was 44 kgs, temp 37,5 degrees C, pulse 112, and RR 22. His lung exam was notable for few scattered crackles bilaterally, bases more than apexes. His Chest X-ray is shown above.

Ideas? Differential Diagnosis? I thought it might be interesting to compare what the work-up would be in an academic center in New York verses Puerto Barrios, where diagnostic tests are limited (to say the least). What says my Director of ICU Megalopolis Academician Geniusy Amigita Lolita?

On the Living Room Floor...

The scorpions and spiders battle for turf. For reference, the spider-diameter is almost the same size as a CD! (or at least 75% of the size).

Goodbye Rafa

Rafa says the recent medicine-related posts on this blog are "boring." Maybe these pictures from his goodbye party will interest him. First, to dispel a common rumor, life here is more than just a constant party. We actually work during the week. Now, about the party:

Rafa, Project Barrios Logistician, is leaving next week. He is going to a MSF Logistics training course/conference near Bogotá Colombia, then home to País Vasco (aka Basque Country). Happily, Ángeles, the former logistician for the Olopa Chagas Disease project, will take Rafa´s place.

We had a party on Friday night to say goodbye to Rafa, Dolors, and Jairo, and to welcome Ángeles. Conrado and Rafa arranged to buy a pig several weeks before the party. They snapped the above pic on a site visit to ensure the pig was fat enough to feed the expected guests.

The day of the party, Norma hacked the pig to bits with an ax (pic at right). Droplets of piggy-juice flew everywhere. It was disgusting. If I was not a vegetarian already, I´m sure this sight would have converted me.

I will not describe the details of the beer and liquor purchase, as I did not get a picture of the bottles, and I´m sure nobody will believe me without it. It will suffice to say that we bought enough to double or triple the LFTs of 80 guests.

Pichi barbecued pig meats while Norma made stew from various internal organs. We also made guacamole, yucca, salad, tortillas, and mojitos. The guests feasted like ravenous carnivores. Magdalena (at left) said the food tasted good. I spent my time documenting the transformation from cute piggy to bubbling stew, the last pork incarnation pictured at right.


I am in no mood to deal with my sentimental side, so I will not ramble about how much we will miss Rafa etc etc. I just hope he will eat more of this stew before he leaves, so we can get this pig out of our fridge.

The Family Visits

My family and a couple of friends from New York visited me in Eastern Guatemala over the weekend. If big smiles are an accurate indicator, they appeared to enjoy the trip (despite bats in the bungalows and other assorted minor mishaps).

We traveled down the Rio Dulce to the mouth of Lago Izabal. Mom kayaked and toured the nearby village. Her less active offspring drank beers and watched the sunset over the river.

After my parents left on Dec 31st (pic at right below), we boated back to Livingston. Somebody in the boat mistook my sister for an Evangelical. There is a first time for everything, I suppose.

Back in Livingston, we drank and danced in the new year with Conrado, Rafa, and Pichi. Jenny´s smile (above) is just after midnight, Jan 1 2007.

I spent the weekend feeling fortunate that I have such an amazing family!