Monday, January 15, 2007

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?


Anonymous said...

Hi Nelly, I know that you said no more radiation questions, but for those of us non medical types, what are we looking at in that chest x-ray? What is abnormal about it?

Lola said...

A very interesting case to be sure. 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. Here in NYC he would certainly get a CT scan of the chest, not so much because it's 100% necessary, but because the pictures are so much prettier; induced sputum for AFB and PCP, and if that were negative bronchoscopy with BAL +/- transbronchial biopsies. A pretty different evaluation than the MSF clinic can provide, but any better? Who can say.

Anonymous 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. Magda

dysphoric said...

Thanks for the ideas. I actually have a solution for at least part of this patient´s problem list, but the internet has been down for two days and I have to run right now. I will keep you in suspense until I can get back on-line.

I miss both of you so much I can barely stand it! I saw 25 new AIDS patients today, all with pulmonary and infectious problems that I can´t solve without your help.
love love love-- Nell

Anonymous said...

yup, classic somatization to me

-btw by her extensive writeup, I suspect LOLA has too much time on her hands in her new job, perhaps not enough business in the units downtown