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NYU Medical Grand Rounds Clinical Vignette. Mark H. Adelman, M.D. PGY-2 2/19/13. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. 43 year old man presents with headache, neck pain for approximately one week.

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nyu medical grand rounds clinical vignette

NYU Medical Grand Rounds Clinical Vignette

Mark H. Adelman, M.D.

PGY-2

2/19/13

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

chief complaint

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • 43 year old man presents with headache, neck pain for approximately one week
history of present illness

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • Diagnosed with HIV in 2002, on HAART until he lost insurance in 2009
  • Doing well until 10 days prior to admission, felt like there was “fluid swishing in my ears”
  • Four days later, vomited multiple times, began to experience headache and neck stiffness
history of present illness1

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • Presented to ER, head CT, left AMA prior to complete evaluation
  • Headache, neck stiffness, nausea/vomiting continued
  • No relief with naproxen, ibuprofen
  • Returned to ER for unremitting headache
additional history

Additional History

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • Past Medical History:
    • Bipolar II
  • Past Surgical History:
    • Hernia repair as a child
  • Social History:
    • No tobacco. Rare alcohol. Infrequent intranasal cocaine, semi-weekly cannabis use
    • Sex with men
  • Family History:
    • noncontributory
  • Allergies:
    • No known drug allergies
  • Medications:
    • Naproxen, ibuprofen as needed
physical examination

Physical Examination

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • General: Well appearing man, alert, in mild distress
  • Vital Signs: T: 97.5, BP: 125/78, HR: 55,
  • RR: 16, O2 sat: 96%RA
  • Neck pain with flexion/extension
  • Remainder of Physical Exam was normal
laboratory findings

Laboratory Findings

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • CBC: Hemoglobin 16.7
    • Remainder of CBC was within normal limits
  • Basic metabolic panel: Potassium 3.5
    • Remainder of basic was within normal limits
  • Hepatic panel: ALT 74
    • Remainder of hepatic panel was within normal limits
laboratory findings1

Laboratory Findings

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • CSF
    • Opening pressure 37
    • 12 WBCs (84% lymphocytes, 16% monocytes)
    • Protein 64
    • India ink, culture, cryptococcal antigen, HSV PCR pending
  • Blood cultures: pending
  • CD4 count and HIV-1 RNA: pending
other studies

Other Studies

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • Chest X-Ray: 1cm nodular opacity in right midlung
  • CT head: no acute intracranial findings
slide10
UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Working or Differential Diagnosis

  • Cryptococcal meningitis
  • Viral meningitis
  • HSV encephalitis
slide11
UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Hospital Course

  • Hospital Day 1:
    • Amphotericin, flucytosine. Acyclovir
  • Hospital Day 2:
    • CD4 count 52 (5%). HIV-1 RNA 28,400.
    • Trimethoprim-sulfamethoxazole
    • Repeat lumbar puncture
slide12
UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Hospital Course

  • Hospital Day 3:
    • CSF India ink stain + for cryptococcus
    • CSF cryptococcal antigen + (1:8,192)
    • Serum cryptococcal antigen + (1:32,768)
    • CT chest: Multiple round, nodular opacities right lower lobe. Mediastinal, pretracheal, right hilar lymphadenopathy
slide13
UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Hospital Course

  • Hospital Day 4:
    • Headache improved
    • HSV PCR negative. Acyclovir discontinued
    • HD#1 CSF fungal culture + for cryptococcus
  • Hospital Days 5-7
    • Induced sputum negative for AFB x3
    • HD#2 CSF fungal culture + for cryptococcus
    • Blood cultures + for cryptococcus
    • Bronchoscopy: BAL, transbronchial lymph node/lung biopsies negative for AFB, + for cryptococcus
slide14
UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Hospital Course

  • Hospital Day 8:
    • Repeat LP: opening pressure 36
    • Cryptococcal antigen 1:512. Culture negative. VDRL +
    • IV penicillin G
  • Hospital days 9-14
    • Recurrent headaches
    • serial LPs until opening pressure 20. Cultures negative
    • Right occipital lymphadenopathy
slide15
UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Hospital Course

  • Hospital Day 15
    • Amphotericin, flucytosine discontinued
    • Oral fluconazole started
  • Hospital Day 16
    • Fine needle aspiration of occipital lymph node
  • Hospital Day 18
    • IV penicillin discontinued
    • FNA + for cryptococcus
    • Discharged home with virology follow-up in one week
slide16
UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Final Diagnosis

  • Disseminated cryptococcosis
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