Download HIV infection

Medical Grand Round
R2 박철기/Prof. 이미숙
강O혁 (M/43)
Adm. 2007. 11. 12

Chief Complaints
sore throat, odynophagia

onset ) 2 months ago
Present Illness
내원 2달 전부터 sore throat 로 local 에서 tonsilitis 의심하 항생제 포함한
약물 치료 받았으나 호전없고 내원 1달전부터 odynophagia 발생하여 본원
ENT 외래 방문하여 tonsillectomy 권유받았으나 거절하고
methylprednisolone 투여( 8mg bid x 7 days) 받음. 이후 증상 약간 호전되
었으나 1주 전에 구강내 whitish patch 발견되고 이후로도 sore throat,
odynophagia with mild dysphagia 지속되어 시행한 EGD에서 Candida
esophagitis 로 진단받고 본원 소화기 내과 방문 예정중 상기 증상 심하여
ER 통해 further evaluation 위해 입원

Past medical Hx
DM/HTN/Hepatitis/Tbc ( - / + / - / - )


HTN : Amlodipine 5mg qd. (7년 전)

OP Hx : UPPP for sleep apnea ( 2년 전)
Family Hx
:None

Personal Hx
- smoking (-)
- alcohol(+) : 소주 2병/ 회, 2~3회/wk
- 2년 전 divorced
- 사업체 운영, 중국에 자주 다녀옴
Review of the systems

General
fatigue(+) weight loss(-) fever(-) chills(-)

Skin
rash(-) pigmentation(-) Itching(-)

Head & neck
headache(-) dizziness(-) neck pain(-)
visual disturbance(-)
Mouth : soreness (+) hoarseness (+)

Respiratory
cough(-) sputum(-) dyspnea(-)

Circulatory
chest discomfort(-) orthopnea(-) palpitation(-)

Gastro-intestinal Odynophagia (+) dysphagia(+)
Anorexia (+) nausea(-) vomiting(-) diarrhea(-) constipation(-)
abdominal pain(-)

Genito-urinary
dysuria(-) frequency(-) nocturia(-)

Musculoskeletal pain(-) weakness(-)

Neurologic
dizziness(-) weakness(-) tingling sense(-)
PHYSICAL EXAMINATION

V/S : 130/70 mmHg - 78/min - 20/min - 36.5℃

General appearance
Alert mental status with acute ill-looking appearance

Head & neck
Normocephaly
No thyroid enlargement , No palpable thyroid mass
No palpable enlarged lymph node
No neck vein enlargement

Eye & ENT
Isocoric pupils with PLR(++/++)
PI (+)
PTH(+/+)
oral ulcer(+) : soft palate (both, 1.5x1.5cm)
PHYSICAL EXAMINATION

Chest
Symmetric chest expansion
Clear breath sound without rale or wheezing
Regular heart beat without murmur

Abdomen
Soft & flat abdomen
Normoactive bowel sound
No hepatosplenomegaly
Abdominal Tenderness/Rebound tenderness(-/-)

Genitourinary
Genital ulcer (-)
condyloma (-)
Back & Ext.
CVA Td(-/-)
pretibial pitting edema(-/-)

Initial assessment & plan

1. Oral ulcer
R/O acute pharyngitis
 Nutritional support with vitamin supply
Throat swab & antibiotics if fever develops
ENT consult

2. suspicious Oral & esophageal candidiasis
 Gastroscopy with biopsy
Viral marker study incl. HIV, HSV & CMV
HbA1c & GMT Check
Blood culture
Oral nystatin & anti-fungal agent if needed

3. Known HTN
 medication 유지
Initial lab. finding
CBC/DC
9,070/mm3- 10.9 g/dL – 31.7 % - 356,000/㎣ (Seg. 70.8 %)
Chemistry
Pro/Alb
T-cholesterol
AST/ALT
BUN/Cr
Glucose
Na/K/Cl
CRP
FeNa : 0.4
TB/DB :0.58/0.12
FeBUN
2.5 mg/dL
7.5/3.0 g/dL
143 mg/dL
25/19 U/L
61/2.8 mg/dL
98 mg/dL
138/4.6/103 mmol/L
12.0 mg/dL
ALP/rGT
HbA1C
69/45 U/L
5.8 %
Urine analysis
RBC 0-1/HPF
WBC 0-1/HPF PH 5.0
S.G. 1.025
Protein (-)
Glucose (-)
O.B.(-)
ketone (-)
Initial lab. finding

Anti-HBs Ag(-)
Anti-HBc Ab(+)

Anti-HAV IgM / IgG ( - / + )

Anti-HCV Ab (-)

Anti-HIV Ab(+) (419.62)
Anti-HBs Ab(+)
Chest X-ray
Electrocardiography
Clinical course (1)
10
9
HIV (+)
Western blot (+)
CD3 T cell 762/ml
CD4 T cell 554/ml
CD8 T cell 210/ml
Anti-Toxoplasma Ab IgG/M(-/-)
Anti-CMV Ab IgG/M (-/-)
EBV VCA IgG/M (+/-)
EBNA (-)
Heterophil Ab (-)
8
7
6
5
4
NR S
Fl u c o n a z o l e
G a s t ro s c o p y
3
2
1
0
Nystatin syrup 500,000u tid
100mg po
11/12
100mg iv
11/15
11/19
200mg iv
11/21
11/25
Clinical course (1)
10
9
8
7
6
NR S
Fl u c o n a z o l e
G a s t ro s c o p y
5
4
3
2
200mg iv
1
MPD 30mg iv
0
11/26
11/30
12/3
PDL 20mg PDL 10mg PDL 5mg
12/7
12/11
Final diagnosis & treatment

Final diagnosis
- HIV infection
- Oral & esophageal candidiasis
- Idiopathic esophageal ulcer

Treatment
- Nystatin syrup (11.22-12.11)
- IV Fluconazole (11.12-12.3)
- Steroid Therapy (2007.11.26~2008.01.3)
Methylprednisolone 30mg IV for 1 wk → Prednisolone PO 20mg
with tapering → 5mg으로 퇴원
OPD F/U

Treatment
Prednisolone 5mg → 2008.1.3 까지 사용후 증
상 호전되어 복용 중단함
For HIV infection
Efavirenz 600mg qd + Zidovudine 300mg bid +
Lamivudine 150mg bid from 07.12.20 to 08.2.13
skin rash with itching sensatioin 로 인해 약제 변경
Lopinavir/ritonavir 800/200 mg qd + zidovudine
300mg bid + Lamivudine 150mg bid from 08.2.14

Gastroscopy (07. 11. 12)

Gastroscopy (07. 11. 12)
Esophageal biopsy (2007.11.12)
HE x200
Esophageal biopsy (2007.11.12)
HE x400
 Gastroscopy (07.11.21)
 Gastroscopy (07.11.21)
F/U esophageal biopsy (2007.11.21)
HE x200
 Gastroscopy (07.11.27)
F/U esophageal biopsy (2007.11.27)
HE x200
 Gastroscopy (07.12.07)
Review Of Case
 1.Management
of newly diagnosed
HIV infection
 2.Oropharyngeal
& esophageal
manifestation in HIV infection
HIV virus

the family of human retroviruses
(Retroviridae) and the subfamily of
lentiviruses

Reverse transcriptase (+)

First isolated in 1983 from a patient
with lymphadenopathy
Prevalence & Incidence

More than 95% of people
living with HIV/AIDS
reside in low- and
middle-income
countries; ~50% are
female, and 2.5 million
are children <15 years
Transmission

Male to male sexual
contact is decreasing
from 64% in 1985 to
42% in 2005.
Heterosexual contact
has increased
dramatically, from 3% in
1985 to 31% in 2005.

Women are increasingly
affected from 7% in
1985 to 27% in 2005.
Screening & Diagnosis

Alternative method
: direct detection of HIV-1
p24 antigen or HIV RNA
level check
Evaluation of HIV (+) patient

CD4 cell count & HIV-1 RNA levels
CD4 T cell : critical for determining patient's disease stage and
short-term and mid-term risk of opportunistic complication, and for
assessing need to recommend prophylasix against opportunistic
infections & initiation of antiretroviral therapy
HIV-1 RNA level : critical for determining viral burden, assessing
potential rate of loss of CD4 cells, and evaluating mid-term & longterm risk of oppotunistic complication.
adjunctive to CD4 cell count in assessing need to recommend
antiretroviral therapy.
General Laboratory tests
Oppotunistic infection
Oppotunistic infection
Oppotunistic infection
Treatment of HIV (+) patient
HAART in HIV treatment
Oropharygeal manifestation in
HIV infection
1.Thrush
I. oral cavity
Oropharyngeal disease is a
frequently recognized complication
in HIV-infected patients.
•
•
Candida infection
frequently is the first manifestation of
HIV infection generally occur in
patients with CD4+ T cell counts of
<300/µL
•
white, cheesy exudate, often on
erythematous mucosa in the
posterior oropharynx, most
commonly seen on the soft palate
•
direct examination of a scraping for
pseudohyphal elements.
short course of antifungal agents,
either local (clotrimazole troches) or
oral systemic
medications(ketoconazole,
fluconazole,itraconazole)
•
Oropharygeal manifestation in
HIV infection
I. oral cavity
2.Hairy leukoplakia
• presumed due to EBV
• generally occur in patients
with CD4+ T cell counts of
<300/µL
• white, frondlike lesions,
generally along the lateral
borders of the tongue and
sometimes on the adjacent
buccal mucosa
.
Oropharygeal manifestation in
HIV infection
I. oral cavity
3.Aphthous ulcer
• unknown etiology
• posterior oropharynx are
also seen with regularity in
patients with HIV infection
• quite painful and interfere
with swallowing
• Topical anesthetics provide
immediate symptomatic
relief of short duration
.
Esophageal manifestation in
HIV infection
II. Esophagus
At least one-third of HIV-infected patients experience esophageal
symptoms
Opportunistic infections are by far the most common cause of
esophageal disease
Initial manifestations of HIV infection.
Esophageal manifestation in
HIV infection
II. Esophagus
1.Candida esophagitis
•
•
•
•
•
•
one of the most frequent opportunistic
infections in patients with AIDS
precipitated by the use of
antibiotics or corticosteroids
dysphagia is the primary complaint,
Less frequently, odynophagia ,
heartburn, substernal chest pain
systemic dissemination does not occur,
because the infection is limited to the
superficial squamous epithelium.
not a fatal disease but a marker of
significant immunodeficiency.
oral systemic antifungal agents such
as Fluconazole
Esophageal manifestation in
HIV infection
II. Esophagus
2.CMV esophagitis
•
•
•
•
•
•
The most common viral cause
of esophageal disease.
Odynophagia is the most
consistent symptom. but
dysphagia is distinctly
uncommon
Viremia can frequently be found
Endoscopy is the diagnostic
method of choice with one or
more well-circumscribed ulcers.
Associated with concurrent
extraintestinal disease
Anti-viral agent (gancyclovir)
Esophageal manifestation in
HIV infection
II. Esophagus
3.HSV esophagitis
•
•
•
•
In contrast to its occurrence in
the immunocompromised host
after transplantation or
chemotherapy, HSV esophagitis
is relatively uncommon in HIV
infection
odynophagia and substernal
chest pain are the most
frequent complaints
The most common endoscopic
findings are a diffuse erosive
esophagitis or multiple shallow
ulcerations
Acyclovir is effective therapy
Esophageal manifestation in
HIV infection
4.Idiopathic esophageal ulceration
• Diagnosis of Exclusion
1) Discrete ulcer seen at endoscopy
2) Histologic examination revealing tissue necrosis and inflammation
consistent with ulceration
3) No evidence of viral inclusion disease or other etiologic agents
identified with routine or special staining
4) No clinical or endoscopic evidence of reflux disease or
drug - induced esophagitis
• Odynophagia which is usually severe, dysphagia, and
substernal chest pain
Esophageal manifestation in
HIV infection
• Endoscopic appearance is one of single or multiple
ulcerations of variable depth with intervening mucosa
normal.
• Clinical, radiographic, and endoscopic findings are
impossible to distinguish from CMV esophagitis
• Corticosteroid therapy results in a dramatic response.
Prednisone 40 mg/d po tapering 10 mg/wk for a 1-month
course
Esophageal Ulceration in Human Immunodeficiency Virus Infection: Causes, Response
to Therapy, and Long-Term Outcome
C.Mel wilcox, David A. Schawrtz, W. Scott Clark
Ann. Of Int. medicine 1995; Vol.123 Issue 2 ;143-149
Esophageal Ulceration in Human Immunodeficiency Virus Infection: Causes, Response
to Therapy, and Long-Term Outcome
C.Mel wilcox, David A. Schawrtz, W. Scott Clark
Ann. Of Int. medicine 1995; Vol.123 Issue 2 ;143-149
Esophageal Ulceration in Human Immunodeficiency Virus Infection: Causes, Response
to Therapy, and Long-Term Outcome
C.Mel wilcox, David A. Schawrtz, W. Scott Clark
Ann. Of Int. medicine 1995; Vol.123 Issue 2 ;143-149