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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
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 & 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
Follow up

Case I Case II

  • CXR bil. infiltrates/opacities Similar
  • CD4 8/mm3 12/mm3
  • When 1994 2008
  • Where NY Ethiopia

What is the likely diagnosis? Prognosis?


Case I Case II

Sputum AFB smear -ve 3X -ve 3X

Blood culture -ve not av.

Cryptococcal Ag not reactive not av.

BAL No PCP not av.

O2 Saturation 60% not av.

CT of chest Bil. infiltrates not av.

effusion/ empyema

how do you manage these patients
How do you manage these patients?

Case I Case II

Hosp. admission Yes No

Antibiotic IV; broad Spec. Amox.(PO)

TMP/SMX Yes (IV) Yes (PO)

Pleural Tap Yes Not done

Supportive Care Aggressive Minimal

diagnosis severe bacterial pneumonia empyema
Diagnosis: Severe bacterial pneumonia; Empyema

Case I Case II

  • Outcome alive with CD4 Expired 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
bacterial infections in hiv aids
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
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
Radiologic Finding

Chest x-ray

CT chest

biopsy finding malakoplakia
Biopsy Finding“Malakoplakia”

Michael’s Guttmann bodies

Foamy macrophages

culture result
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
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
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 up1
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
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
Autopsy Findings



GMS stain

Mucicarmine stain

case iv autopsy diagnosis
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
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
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
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
Next session: January 21, 2010

Dr Roy Colven

HIV Dermatology: Virtual Office Hours

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