11/3/17 Intern Morning Report – Joint pain, Fevers, Recent Diarrheal Illness, Oligoarthritis, HIV, Reactive Arthritis

CC: Joint Pain

HPI: This is a 32 year old male with history of chlamydia and new diagnosis of HIV who presents for painful joint swelling in bilateral knees and wrists for 5 days. He reports that approximately 3 weeks prior to admission, he experienced 1 week of abdominal pain, diarrhea, and fevers. While the GI symptoms resolved, he has had on and off fevers since. Five days prior to admission, he began to have bilateral wrist pain with swelling which then progressed to to his left knee followed by his right knee over the course of a few days. His social history is notable for being sexually active with both males and females with greater then 30 partners over the last few years.  His exam is pertinent for bilateral wrist and knee swelling, warmth and tenderness. There is difficulty ranging the joints with both passive and active motion.  Skin and lymph node exam is normal though.  Given history and exam consistent with an inflammatory oligoarthritis in the setting of recent gastrointestinal infection, reactive arthritis high on the differential but could not rule out disseminated gonococcal infection or atypical presentation of crystalopathy, septic joint, or rheumatoid arthritis.  Joint aspiration from wrist significant for a leukocyte count of >90,000 with >75% PMNs so patient initiated on antibiotic therapy for septic joint treatment.  However further studies on synovial fluid unrevealing including gram stain, culture, and crystals.  Serologies were also sent which showed a negative ANA, mildly elevated RF, and negative Anti-CCP.  Mucosal swabs for gonorrhea negative and though patient high risk, without other findings of disseminated gonococcal infection (DGI) like tenosynovitis, pustular rash, and migratory arthritis nor positive cultures from non-mucosal sites, DGI considered unlikely. With the clinical picture involving a recent diagnosis of HIV as well as a diarrheal illness in addition to negative infectious and crystallopathy work up, a diagnosis of reactive arthritis was made.

Some Notable Labs:

Wrist Synovial Fluid:
(H) 96,000 leukocytes/cumm
(H) 92 % PMNs

Gram stain and culture negative

  • CRP 170 (>7 high)
  • ESR 90 (0-22)
  • ANA Negative
  • RF: 58 (normal high 13)
  • Anti-CCP: <16
  • HLA B27 Positive

Right sided supra patellar effusion, otherwise normal X-rays.


Morning Report Pearls:

Though cases do not always fit the classic presentation, it can be useful to breakdown etiologies of joint complaints by the number involved.

Monoarthritis Differential

Oligoarthritis (2-4 joints) Differential

Polyarthritis (>5 joints) Differential

1. Acute Infection: Bacterial

2. Subacute/Chronic Infection: Fungal, TB, Lyme

3. Crystal Disease: CPPD, Gout

4. Osteoarthritis

5. Trauma

6. Monoarticular Rheumatoid Arthritis

1. Spondyloarthropathies: AS, Psoriatic arthritis, Reactive arthritis, IBD

2. Disseminated Gonococcal

3. Rheumatic Fever

4. Lyme Disease

5. Osteoarthritis

1. Chronic inflammatory: Rheumatoid arthritis, SLE, Psoriatic, Vasculitis

2. Acute Viral: Hepatitis, Parvo, Rubella, HIV, Enterovirus

3. Drug Induced Serum Sickness

 

 

Synovial Fluids Studies are important in differentiating non-inflammatory conditions from inflammatory. Also the degree of leukocyte elevation can provide useful information for determining an etiology.

Synovial Fluid Leukocyte Count:

<200 = Normal

200-2,000 = Non-Inflammatory

2,000 = Inflammatory

50,000 = High Concern for Septic Joint however Crystal Disease, Reactive Arthritis and other autoimmune disorders like Rheumatoid Arthritis can not be completely excluded

 

Mildly elevated Rheumatoid Factor occurs in the general healthy population and also be positive in certain infections and/or autoimmune conditions.  RF is very sensitive for the diagnosis of Rheumatoid Arthritis but that means it can include a higher number of false positives so mildly elevated results in the incorrect clinical picture needs to be scrutinized.  The fact that Anti-CCP is negative, a specific test, makes RA diagnosis less likely in this case as well.

9/12/17 Resident Morning Report – Dyspnea on Exertion, HIV/AIDs, Pulmonary Hypertension, Ischemic Liver Injury

CC: Dyspnea on exertion

ID: This is a 52 year-old male with history of HIV intermittently taking antiretrovirals that presents with 2 months of progressive dyspnea on exertion. His functional status has slowly declined and patient can barely walk a block before becoming short of breath.  Patient denies any skin rash, fevers, recent URI, cough, night sweats, recent travel, orthopnea, or extremity swelling.  On exam patient requiring 6L NC to saturate >92%, tachypneic to 26, with a lower blood pressure then is typical for him, around 100/70.  He has clear lung fields but there is notable increase in his JVP as well as cold extremities on physical exam.

Notable Labs/Studies:

ABG: pH 7.43/ PCO2 28mmHg/PO2 45 mmHg/ HCO3 12

AST/ALT: 3960/1140

Tbili/Direct Bili: 3.1/2.2

Utox positive for amphetamines and opiates

CD4 count 110

 

 

Given clear CXR, evidence of right heart hypertrophy and strain on EKG, and elevated JVP on exam TTE pursued which demonstrated significant pulmonary hypertension.  This was followed by right heart catheterization (see values below).  His severe pulmonary hypertension was thought to from HIV but drug use could not be excluded.  He was not vasoreactive on catheterization so calcium channel blockers could not be used in his management.  Liver was consulted for the transaminase elevation and after excluding other etiologies, believed this hepatocellular injury to be from ischemia due to severe right heart failure and poor cardiac output.

 

Right Heart Catheterization:

  • CVP 14
  • PAP mean 68
  • PA systolic/PA diastolic: 109/49
  • PCWP: 12
  • CO/CI: 2.85/1.6

Teaching Points:

Remember causes of hypoxia with a normal chest x-ray:

-Asthma, Pulmonary embolism, Early PNA, ILD, Early PCP, Pulmonary Hypertension, Shunts, Hypoventilation

 

Know the Criteria to diagnosing Pulmonary Arterial Hypertension:

  1. PAP mean >25
  2. Pulmonary Artery Resistance >3 woods units
  3. Wedge pressure <15

 

To Diagnose Pulmonary Hypertension secondary to HIV, it is necessary need to exclude other causes.  Important studies to pursue to work up other WHO Classifications of Pulmonary Hypertension:

  • Transthoracic Echocardiogram
  • V/Q Scan
  • PFTs
  • Polysomnography
  • Autoantibody testing
  • High resolution CT