Embed Size (px)
Citation preview
Case discussion
Hung-Chin Tsai, MD, PhD.
Section of Infectious Diseases and Office of Infection Control, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
Case Presentation
• 25 years old, MSM, raise a dog
• Acute HIV infection found by our VCT in Nov 2012, then loss of follow up.
• Infection OPD in Aug 2013. CD4:661 cells/ul,VL:180000 copies/ml
• Infection and ENT OPD in Feb, 2014. CD4:583 cells/ul, VL:290000 copies/ml. multiple neck LAP for months. Then subsided spontaneously
• Infection OPD in Mar 2016. CD4:695 cells/ul,VL:161000 copies/ml
Case Presentation
• 2016/08/04 INF OPD: fever, cough with sputum for days
• Had travel to Thailand 2016/7/29-2016/8/3
• Multiple varied size LAP over neck, axillary and inguinal area, with tenderness, soft, movable
• Lab data: WBC 8600/cumm, HgB 9.8 g/Dl, PLT 32000/cumm, LDH 298U/L (95-213 U/L)
• CD4:567 cell/ul, VL:753000 copies/ml
Diagnosis
1. HIV with multiple lymphadenopathy 2. Fever, suspect sepsis
Case Presentation(2016/8/4-2016/8/17)
• 2016/8/4: Platelet blood transfusion, and ceftriaxone use, Dengue NS1-, Toxoplasma Ab-, serum cryptococcus Ag-
• 2016/8/5: BM biopsy: hypocellular BM
• 2016/8/7: HAART with Combivir and Kaletra
• 2016/8/8: left neck punch biopsy
• 2016/8/16: left neck excisional biopsy
2016-08-05
2016-08-08
2016-08-08 2016-08-25
日期 WBC RBC HGB HCT MCV MCH MCHC RDW PLT
單位x1000/Cumm
m/Cumm
g/dL % fl pg g/dL %x1000/Cumm
2016-08-15
9.2 3.27 9.7 28.6 87.5 29.8 34.1 14.3 351
2016-08-07
6.1 3.28 9.6 27.9 85.1 29.1 34.2 14.4 34
2016-08-06
8.7 3.31 9.6 28.3 85.5 29.0 33.9 14.5 11
2016/8/7 Dexamethasone 5mg IVD st, after platelet blood transfusion
Case Presentation (2nd admission)
• 2016/08/20 ER: abdominal, inguinal area, hip pain with fever and poor night sleep for days
• Lab data: WBC 11200/cumm, HgB 10.9 g/dL, PLT 15000/cumm, CRP 10.98 mg/dL
• Urine routine: RBC 50-99/HP, no pyuria
• Blood culture: negative
• 2016/8/22 Neck L.N biopsy: Kaposi’s sarcoma
• Treatment : dexamethasone 5mg q6h, keep HAART, Platelet blood transfusion at ER
Case Presentation (2nd admission)
• 2016/08/23: Anemia and for future C/T, HAART was switched to truvada and Kaletra
• 2016/8/24: inguinal L.N biopsy: KS
• 2016/8/25: diffuse abdominal pain and fullness with fever. Emergent CT scan, hold kaletra, empirical cefepime and metronidazole use, NPO and NG decompression.
• 2016/8/26: C/T with liposomal doxorubicin
Emergent Abdominal CT scan 2016-8-25
Case Presentation (2nd admission)
• 2016/8/27: Oral candidiasis , low PLT 23k with hemoptysis. Fluconazole was prescribed and blood transfusion with platelet done
• 2016/8/29: CXR : right pleural effusion, PLT 11K, shock and norepinephrine (Levophed) was used (2916/8/29-2016/8/31), still hemoptysis and penile echymosis, critical care, HAART was switched to truvada+raltegravir, PRBC and PLT blood transfusion
2016-8-28 2016-8-29
Case Presentation (2nd admission)
• 2016/8/30: Panendoscopy
• 2016/8/31-2016/9/5: remarkable body weight increase, hypoalbuminemia, albumin infusion and diuretics use
• 2016/9/6: MBD
• 2016/9/12 OPD: WBC 5700, HgB 11.1, Plt 195K, CD4:706 cell/ul, VL:115 copies/ml
Panendoscopy 2016-8-30
Case Presentation (2nd admission) 日期 ALB TP GOT GPT LDH
單位 g/dL g/dL U/L U/L U/L
2016-09-02 2.1
2016-09-01 23 21
2016-08-30 1.6
2016-08-29 46 37 259
2016-08-27 26 24 194
2016-08-25 2.4 6.1 12 16
2016-08-24 11 13
Case Presentation (2nd admission) 期 BUN CREA Na K UA Ca IP eGFR
單位 mg/dL mg/dL mmol/L mmol/L mg/dL mg/dL mg/dLml/min/1.73
2016-09-04 3.7
2016-09-02 3.9 7.5
2016-09-0145 0.96 139 4.5 7.9 7.0 3.6 101.4
2016-08-31 4.5 10.3 7.4
2016-08-3052 1.15 144 4.3 10.4 8.1 4.5 82.4
2016-08-2956 1.41 138 4.4 8.4 6.9 4.1 65.1
2016-08-2726 0.93 131 4.4 4.5 7.4 3.3 105.2
2016-08-2522 0.84 139 4.3 8.1
2016-08-2419 0.89 133 4.0 110.7
Case Presentation (2nd admission) 日期 WBC RBC HGB HCT MCV MCH MCHC RDW PLT
單位x1000/Cumm
m/Cumm g/dL % fl pg g/dL %x1000/Cumm
2016-09-06
5.6 2.89 9.1 26.8 92.7 31.3 33.8 20.7 130
2016-09-04
5.1 2.92 9.2 26.1 89.5 31.4 35.0 18.5 75
2016-09-02
5.5 3.35 10.1 30.0 89.5 30.2 33.7 19.6 48
2016-08-31
10.5 3.23 10.1 29.3 90.8 31.4 34.6 18.3 30
2016-08-29
16.2 2.87 8.8 26.1 91.1 30.8 33.9 19.6 17
2016-08-29
10.8 2.21 6.9 20.3 91.6 31.2 34.1 21.7 11
2016-08-27
13.7 2.72 8.3 24.9 91.6 30.7 33.5 21.5 23
2016-08-24
18.3 2.86 8.7 26.3 91.8 30.5 33.2 18.8 58
2016-08-23
10.5 3.59 11.0 32.7 91.2 30.5 33.5 18.7 56
Final Diagnosis
• AIDS with Kaposi sarcoma with right upper gingiva and neck, axilary, mediastinum , retroperitoneal and inguinal lymph node, duodenum involvement, s/p lipoxomal doxorubicin on 26 Aug 2016 with shock,hypoalbuminemia and thrombocytopenia , suspected Kaposi sarcoma associated inflammatory cytokine syndrome(KICS)
Clinical Infectious Diseases 2016;62(6):730–8
Kaposi sarcoma incidence rates overall and stratified for
selective risk factors by time periods since starting HAART
Clin Infect Dis advance access published August 17, 2016
Clin Infect Dis 2010;51:250-358
Incidence rates of KS by calendar period, overall and
according to HIV transmission category
Swiss HIV cohort Br J Cancer 2008;99:800-804
HAART non-usersa HAART users
KS pyIncidence/1000py (95% CI)b HR (95% CI)c KS py
Incidence/1000 py (95% CI)b HR (95% CI)c
Overall 545 37 86115.0 (13.8–16.3)
1d 52 35 551 1.3 (1.0–1.7) 0.11 (0.08–0.14)
HIV transmission category
MSMd 446 10 900 27.8 (25.3–30.5) 1 35 12 216 1.6 (1.1–2.3) 1
Het/Oth 62 10 183 8.9 (6.8–11.4) 0.27 (0.20–0.36) 16 13 796 1.2 (0.7–1.9) 0.54 (0.27–1.10)
IDU 37 16 778 2.1 (1.5–2.9) 0.09 (0.06–0.13) 1 9539 0.0 (0.0–0.3) 0.05 (0.01–0.37)
Age at enrolment (years)
<35d 256 27 795 7.4 (6.5–8.4) 1 25 20 136 0.9 (0.6–1.3) 1
35 289 10 066 17.6 (15.7–19.8) 1.53 (1.29–1.82) 27 15 416 1.4 (1.0–2.1) 1.07 (0.61–1.85)
Place of birth
Europed 529 36 334 15.0 (13.8–16.4) 1 43 32 495 1.0 (0.7–1.4) 1
Africa/Middle East
16 1527 12.5 (7.1–20.4) 1.84 (1.10–3.06) 9 3057 2.4 (1.1–4.6)6.49 (2.79–15.11)
CD4 cell count at enrolment (cells l -1)
350d 128 20 988 6.7 (5.6–8.0) 1 18 15 212 1.0 (0.6–1.6) 1
200–349 93 6126 15.3 (12.4–18.8) 2.44 (1.86–3.20) 9 8382 0.9 (0.4–1.8) 0.84 (0.38–1.88)
50–199 133 3883 33.6 (28.2–39.9) 5.04 (3.90–6.51) 11 7556 1.1 (0.6–2.0) 1.13 (0.53–2.44)
<50 94 1119 77.1 (62.3–94.3)12.85 (9.59–17.23)
12 3021 4.8 (2.5–8.4) 3.26 (1.53–6.91)
Unknown 97 5745 18.1 (14.7–22.1) — 2 1381 0.7 (0.1–2.7) —
Treatment interruption e
Nod — — — — 28 27 234 0.9 (0.6–1.2) 1
Yes — — — — 24 8317 2.8 (1.8–4.1)8.14 (4.01–16.54)
Br J Cancer 2008;99:800-804
Rational Therapeutic Approaches in KICS
• Little experience, difficult to treat
• Ganciclovir with activity against KSHV
• High doses of zidovudine or ganciclovir (KSHV lytic gene, ORF36, encodes a hosphotransferase that activates ganciclovir to a cytotoxic triphosphate moiety, ORF21, encodes a thymidine kinase that phosphorylates zidovudine (AZT), again to a cytotoxic moiety)
• Rituximab to kill B cells that may harbor KSHV or be producing cytokines
• Liposomal doxorubicin to kill KS spindle cells.
Front. Microbiol., 02 March 2012
Case Presentation• 24 years old man, MSM
• HIV was diagnosed by military recruit physical exam in March, 2012
• Had ever took HAART for 1 year at another hospital A (regimen: AZT/3TC and EFV)
• Quit HAART for >6 months , work at breakfast restaurant
• Anti-HBs+, HCV-
• CD4:2 (08/2015), VL: 209000(08/2015)
• Restart HAART with AZT/3TC and LPV/r in Sep 2015
Case Presentation• Nausea and vomiting to HAART (AZT/3TC and LPV/r)
then admitted to ward for survey in Sep 2015.
• Diagnosis : 1. suspected nausea vomiting to HAART .2. LUL and liver nodules , caused to be determined , refuse biopsy
• HAART was switched to TDF/FTC/EFV in Sep 2015, patient tolerant well
• VL:209000(08/2015)-88800(10/2015)
• GRT on 28/10/2015
• Admitted again on 07/11/2015 due to fever, left flank pain with radiation to left lower leg for 1 day
Case Presentation• 2015/11/12 GOT:70U/L, GPT:260U/L, ALP:932U/L
• 2015/11/11 GOT:140U/L, GPT:338U/L, ALP:1010U/L
• 2015/11/10 GOT:343U/L, GPT:487U/L, ALP:1119U/L
• 2015/11/09 GOT:799U/L, GPT:544U/L, ALP:1006U/L
• 2015/11/06 GOT:135U/L, GPT:290U/L
• 2015/11/05 GPT:407U/L, ALP:639U/L, CK:109U/L
• 2015/10/19 GOT:27U/L, GPT:20U/L
• Abdomen CT(11/9):malignancy is possible.(1) A liver nodule, S8, 1.7 cm in size.(2) A lung nodule noted in the LUL, 1 cm in size. s/p sono-guide liver biopsy on 12/11/2015
Sono-guide liver biopsy: EBV associated smooth muscle tumor
2015-11-09
A solid nodule noted in the S8, 1.7 cm in size . The possibility of
metastasis can not be completely ruled out
2015-11-09
A solid nodule noted in the LUL, 1 cm in size. The possibility of lung
cancer can not be completely ruled out.
GRT 28/10/2015
M184V, V179D, G190S
GRT 28/10/2015
L10V
What HAART regimen do you want to choose ?
• AZT/3TC and booster PI (such as LPV/r-)
• TDF/3TC, or TDF/FTC with booster PI
• Integrase inhibitors (raltegravir, doutegravir) and booster PI
• Integrase inhibitors (raltegravir, doutegravir) and booster PI with third drugs
• Others
Admission 2016/3/22-2016/4/2
• 1.Liver smooth muscle tumor, EBV-associated, s/p RFA on 2016/3/30
• 2.left upper lung nodules s/p CT-guided biopsy on 2016/3/31
• 3.AIDS under HAART therapy with virological failure (3TC, NNRTI resistance) on kaletra and Combivir from 2015.11 4.
• Herpes zoster, right C5-T2
Case presentation
• CD4:34(07/2016)-137(09/2016)
• VL:26600(07/2016)-<20(09/2016)
