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NYU Medical Grand Rounds Clinical Vignette. Sunnie Kim, MD PGY3 Tuesday, May 29, 2012. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint.

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nyu medical grand rounds clinical vignette

NYU Medical Grand Rounds Clinical Vignette

Sunnie Kim, MD

PGY3

Tuesday, May 29, 2012

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

chief complaint

Chief Complaint

  • The patient is a 25 year-old man who presents for follow-up for chronic leukopenia and requesting HIV testing and counseling, as well as information about pre-exposure prophylaxis.

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

history of present illness

History of Present Illness

  • History of multiple male sexual partners.
  • Six months prior to presentation was evaluated after a high-risk sexual contact with condom malfunction and penile laceration.
  • Treated with 28-day course of zidovudine, tenofovir and lamivudinefor post-exposure prophylaxis.

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

history of present illness1

History of Present Illness

  • Also evaluated and treated for chronic facial acne vulgaris in dermatology clinic.
  • Having failed topical antibiotics and antimicrobials, was initiated on isotretinoin.
  • During this time, he was noted to have persistent leukopenia and was referred to medicine clinic.

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

history of present illness2

History of Present Illness

  • The patient also requests HIV testing, and counseling on means of prevention, including medications or vaccines.
  • He reports several HIV-negative friends on chronic anti-retroviral therapy for HIV prevention.

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

additional history

Additional History

  • Past Medical and Surgical History
    • None
  • Social History:
    • Multiple concurrent male sexual partners
    • Inconsistent condom use
    • No known history of sexually transmitted infections
    • Occasional MDMA/ecstasy use
    • Occasional alcohol use with intermittent binge drinking
  • Family History:
    • none
  • Allergies:
    • NKDA
  • Medications:
    • Isotretinoin 20mg bid

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

physical examination

Physical Examination

  • Well appearing.
  • Vitals: T97.8F, BP 106/62, HR 61, RR 16
  • Numerous hyperpigmentedmacules and atrophic scars over the face and upper back.
  • Otherwise normal examination

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

prior laboratory findings

Prior Laboratory Findings

  • CBC:
    • WBC 3.1 (N 59%, L 34%, Eos 6%, Baso 1%)
    • Hg 14.1g/dl
    • Platelets 182,000
  • Cr 0.9mg/dl
  • AST 41mg/dl (11-39)
  • ALT 45mg/dl (11-35)
  • The remainder of the hepatic panel and basic metabolic panel was normal

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

slide9

Working Diagnosis

Mildly elevated transaminases with leukopenia

- chronic viral infection

- iatrogenic from chronic acne treatment (antimicrobials or isotretinoin)

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

slide10

Clinical Course

  • The patient received counseling on safe sex practices including consistent condom use.
  • No HIV vaccine is currently available for clinical use.
  • Pre-exposure prophylaxis was not initially offered to the patient due to limited evidence and interim CDC guidelines.
  • Scheduled for follow-up visit for further counseling.

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

slide11

Clinical Course

  • The patient screened negative for HIV, hepatitis B and C, gonorrhea, and chlamydia infections.
  • Repeat CBC showed stable WBC (3.1-5.0)
  • Transaminases normalized after completion of isotretinoin treatment.

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

slide12

Final Diagnosis

Otherwise healthy man engaging in high-risk sexual activities despite counseling.

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS