Most memorable cases dr getachew feleke january 14 2010
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Most Memorable Cases Dr Getachew Feleke January 14, 2010. Objectives. Highlight common and less common infectious complications of HIV/AIDS. Generate discussion on factors that can impact the outcomes of these infections. Generate discussion on when to start HAART in the face of acute OIs.

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Most Memorable Cases Dr Getachew Feleke January 14, 2010

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Most Memorable Cases

Dr Getachew Feleke

January 14, 2010


  • Highlight common and less common infectious complications of HIV/AIDS.

  • Generate discussion on factors that can impact the outcomes of these infections.

  • Generate discussion on when to start HAART in the face of acute OIs.

Case I & II

Case I

  • 42 years old Female presented with cough, purulent sputum, respiratory distress and fever of 2 weeks duration

  • T=1030 F, RR=32 /min, chest- rales and basal dullness

    Case II

  • 28 years old Female with similar history, had completed treatment for TB; sputum was blood tinged

  • T=1010F, RR=28, chest-rales

  • Both were HIV+

Follow up

Case ICase II

  • CXRbil. infiltrates/opacities Similar

  • CD48/mm3 12/mm3

  • When19942008

  • Where NYEthiopia

    What is the likely diagnosis? Prognosis?


Case I Case II

Sputum AFB smear-ve 3X -ve 3X

Blood culture -ve not av.

Cryptococcal Agnot reactive not av.

BALNo PCP not av.

O2 Saturation60% not av.

CT of chest Bil. infiltrates not av.

effusion/ empyema

How do you manage these patients?

Case ICase II

Hosp. admissionYesNo

AntibioticIV; broad Spec.Amox.(PO)


Pleural TapYesNot done

Supportive CareAggressiveMinimal

Diagnosis: Severe bacterial pneumonia; Empyema

Case I Case II

  • Outcomealive with CD4Expired in 2weeks

    600+ in 2008

    What modifiable factors might have contributed to the difference in outcome?

    • Supportive care- oxygen, chest tube, close monitoring

    • Knowledge and skill gap?

    • Attitude of the HW or client?

    • Availability of services( diagnostic, therapeutic) and skilled manpower

  • Up to 25% of cases may not have identifiable bacteria but respond to antibiotics

Infectious etiology in HIV(bacterial/fungal)

Bacterial Infections in HIV/AIDS

  • Bacterial pneumonia is a major cause of morbidity and mortality in HIV/AIDS

  • Choice of empiric therapy should target potential causative agents

  • Severe pneumonia if recognized early is treatable

Case III

HI: 39 years old male diagnosed with HIV a month ago presented with weight loss (10 kg in 2 months) weakness and diarrhea of 3 weeks duration


  • PMH: Cough, hemoptysis and fever 6 weeks ago and improved with Amoxicillin

  • P/E :Sick looking, cachectic, multiple papular skin lesions on the face; dry scaly skin.

  • Lab: CD4= 7/mm3

    : VL= 392,627c/ml

    :Tuberculin skin test-no induration.

Radiologic Finding

Chest x-ray

CT chest

Biopsy Finding“Malakoplakia”

Michael’s Guttmann bodies

Foamy macrophages

Culture Result

  • Gram variable Coccobacilli

  • Weakly Acid Fast

    Identification: Rhodoccous equi


  • Antibiotic: Clarithromycin, Vancomycin

  • HAART: Combivir/Kaletra

  • Prophylaxis: TMP/SMX, Azithtromycin

  • Patient fully recovered; CD4 =400 in 2008

R.equi Pneumonia in AIDS

  • Presentation is sub acute with productive cough & occasional hemoptysis

  • CXR: infiltrates, nodules, cavities, abscess, empyema

  • CD4 < 100;bacteremia is common

  • Treatment: two antibiotics for > 6 wks; generally resistant to Penicillin/Cephalosporin

  • Prognosis in the era of HAART is good.

Case IV

  • 37 years old Hispanic male from central America presented with fever, headache and weight loss of two weeks duration.

  • P/E: cachetic, sick looking, T=1010F

  • Umblicated papular lesions on face.



  • Hgb= 8.6, WBC=10.4 diff. 69% N & 18% L

  • CD4=8/mm3

  • VL=750,000 c/ml.


  • CT of head-No abnormality

    Clinical Decision

Follow Up

  • Blood culture- negative

  • CSF: India ink-positive

    : WBC =18/mm3 with 83% L; 9% N

    : OP = 250 mmH2o

  • Crypt Ag=1:1024

  • Ampho. B 0.7mg/kg/d + Flucytosine

  • Started on Kaletra, AZT+3TC, Azithromycin

  • Improved and discharged on Fluconazole 600mg PO daily.

Follow Up continued..

  • 7 wks later he presented with fever, dizziness, cough and vomiting after being found unconscious in the bath room.

  • T= 101oF, bil. basal rales, CNS :a & o, non focal.

  • WBC=20,500/mm3 with 80%N;13%Bands

  • CXR=bilateral infiltrates; LML cavity

  • CT head- cerebral edema, no mass, no herniation.

    Clinical Decision

Case IV follow up

  • Admitted to ICU, started on Pipercillin-Tazobactam,Vancomycin, Amphotericin B, IV Fluconazole, Dexamethasone

  • LP done: OP= 400 mmH2o, India Ink was positive, Lumbar drain & intra thecal Amphotericin B.

  • Patient deteriorated and died after 3 weeks of hospitalization.

    Clinical Discussion

  • What is the cause of death?

    • Overwhelming Cryptococcal meningitis?,

    • Bacterial super infection? Aspiration pneumonia?

    • IRIS?, (?paradoxical;?unmasking)

Autopsy Findings



GMS stain

Mucicarmine stain

Case IV-Autopsy Diagnosis

  • Acute necrotizing Bronchopneumonia

  • Left lower lung cavity- Cryptococcal abscess

  • Necrotizing granuloma with numerous budding yeast in para tracheal mass

  • Budding yeast in spinal cord

  • Blood culture= Pseudomonas (post mortem)

Cryptococcosis:A major cause of morbidity in AIDS

Cryptococcal Disease Global Burden(Park et al IDSA 2008)

Prognostic factors in Cryptococcal Meningitis

Early Vs Delayed HAART in the setting of Acute OIs

  • 282 subjects; PCP 63%; Crypt. 12%, bacterial infection 12 %. Early HAART had fewer AIDS progression/ death, OR=0.51, CI (0.27-0.94). No difference in safety, toxicity, IRIS at week 48.1

  • 54 Crypt. meningitis cases treated with Fluconazole, early HAART ( with in 72 hrs) had greater mortality (82%) Vs delayed HAART (10 weeks), 32 % overall mortality 62 %.2


2.makadzange (CROI 2008, late breaker

Cause specific mortality and contribution of IRIS in Urban cohort

Method: Determination of cause specific mortality and role of IRIS over 36 months at the IDI of Makerere University.


  • 17% (90) died in 36 months

  • 14 %(80) died with in the 1st year

  • (13%) 73 patients died with in the 1st three months

    Causes of death

  • 69/80 deaths that occurred during the 1st year were AIDS related

  • Only four were attributed to IRIS

Source: Castelnouve CID 2009; 49;965-72


  • Progressive decline in CD4 count increases the risk to all infections

  • Bacterial infections (non TB) are common in HIV/AIDS

  • Early HAART leads to better outcome

  • Cryptococcus remains a common cause of mortality

  • IRIS complicates early management of HIV but may not be enough to delay ART

Next session: January 21, 2010



Next session: January 21, 2010

Dr Roy Colven

HIV Dermatology: Virtual Office Hours

Extra slides

India Ink

“Failure to manage elevated ICP is the most dangerous mistake in management”CID 2005;40:477

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