Tag: immunocompromised

4/21/17 Intern Morning Report – Diarrhea, Hyponatremia, Cryptosporidia

CC: RUQ pain and diarrhea x 6 weeks

ID: 58 yo male with HIV/AIDS (CD4 25) off HAART who presents with 6-8 weeks of persistent cramping, non-radiating RUQ pain, and watery diarrhea.  He was found to have hypovolemic hyponatremia and ultimately work-up revealed cryptosporidium.

Capture

Source: MKSAP 17

Pearls from morning report:

  • Blastocystis species are commonly detected in stool samples, but it is unclear whether this parasite is truly pathogenic. In symptomatic patients who are immunocompromised, a thorough examination for infections and noninfectious causes should be performed. If the work up is negative, then treatment with blastocystis with metronidazole is a reasonable option
  • Ecstasy can cause drug-induced ADH secretion leading to hypotonic hyponatremia.

Random trivia:

Cryptosporidium is the most common cause of recreational water illness outbreaks – caution next time you go to Raging Waters!

Want to read more?

Disorders of Plasma Sodium – Causes, Consequences, and Correction (New England Journal of Medicine)
Hyponatremia (New England Journal of Medicine)

References: 

Sterns RH, Emmett M, Forman JP. Diagnostic evaluation of adults with hyponatremia. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on May 3, 2017)

Sterns RH, Emmett M, Forman JP. Causes of hyponatremia in adults. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on May 3, 2017)

MKSAP 17: Medical Knowledge Self-assessment Program. Philadelphia : American College Of Physicians, 2016. Print.

2/17/17 Intern Morning Report – Red Eye, CMV Retinitis

CC: 1 week of redness of the eye

ID: 54 yo male with HIV/AIDS (CD4 count 96 2 months ago), noncompliant with medications, who presents with redness of the eye for 1 week and blurry vision for 1 month.  Retinal exam was notable for inferior large chorioretinal scar with focal white lesion within the scar, consistent with CMV retinitis.  AC tap was positive for CMV and negative for VZV or HSV.  He was found to have a repeat CD4 count of 34.

red-eye-flowchart

American Academy of Ophthalmology webpage on ophthalmic abbreviations.

Pearls from morning report:

  • For patients with CD4 < 50, remember to get regular ophthalmology exams every 3-6 months.
  • CMV retinitis can be diagnosed based on fundoscopic exam alone – a vitreous tap is not required for diagnosis.
  • CMV retinitis can present as part of the immune reconstitution inflammatory syndrome (IRIS).

Random trivia:

When first discovered, ganciclovir was so efficacious that a placebo-controlled clinical trial could not be ethically be done – the FDA rejected the first application to market the drug.  The pharmaceutical company who developed this drug, Syntex, gave the drug away for free for 5 years under compassionate use guidelines.

Want to read more?

Ocular Emergencies (American Family Physician)
What can you see in your patient’s eyes? Review of ocular manifestations of HIV in HAART era (International Journal of STD & AIDS)

References: 

MKSAP 17: Medical Knowledge Self-assessment Program. Philadelphia : American College Of Physicians, 2016. Print.

Jacobs DS, Trobe J, Libman H. Evaluation of the red eye. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on February 17, 2017)