Download ID Fellows Case Conference - City-Wide Infectious Diseases Case

ID Fellows Case
Conference
August 25, 2010
Lindley Barbee MD, MPH
A classic presentation of an uncommon
disease …except among transplant patients.
An Uncommon Presentation of a
Common Disease
Case
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67 y M w/ small cell lymphocytic lymphoma/chronic
lymphocytic leukemia presents to SCCA for evaluation
for transplant
SLL/CLL dx’d in late 2006 with diffuse LAD
TX course thus far: rituximab, pentostatine,
cyclophosphamide for three months in early 2007
Rituximab, solumedrol for relapse the following year
Rituximab, cytoxan, prednisone in 2009
Since January 2010 – bendamustine, rituximab x 8
cycles
July 2010 radiotherapy with gamma knife to abdomen
Background History
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PMH
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Gout
Benign adenoma of brain
s/p resection 2000
Pituitary adenoma
Melanoma s/p excision
TURP for BPH
Family History
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Father died of colon CA
Mother died of liver CA
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Medications
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Allopurinol
Levothyroxine
Cabergoline
Dexamethasone 0.5mg
Benadryl prn
Marinol prn
Compazine prn
Ambien prn
Background History
Social History
Born Indiana, lives in Carson City NV
In the Marines lived in Japan and San Diego
Travel – Mexico, Kenya & Tanzania
Retired attorney, has a dog, no other animal
exposures. Denies tob, etoh, illicit
 Pre-transplant Serologies
HSV+, VZV +, CMV -, toxo -, HIV p24 
Case
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On 7/21 he had last XRT to abdominal mass
On 7/23 he and his wife left Reno to drive to
Seattle for his pre-txp appt. During the drive
suffered abdominal pain, nausea and
vomiting.
On arrival to SCCA, July 27, he is weak and
sweaty, c/o abdominal pain, n/v.
Labs reveal Na 120.
Pt is admitted to UWMC.
Admission Data
VS: T 36.4 HR 80 BP 140/78 RR 18 100% RA
121 | 88 | 16 /
4.0 | 21 | 0.8 \
Serum Osms 250
Una 53
AST 61 ALT 61 AlkPhos 121
2.99 \
/ 54
/ 38 \
75% polys
18% lymphs
Hospital Course: Days 2 - 4
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Hyponatremia attributed to hypovolemia.
Tx’d with NS and sodium slowly rises
Cort stim is WNL
GI is consulted for abdominal pain, now with
constipation – dx: Radiation Enteritis
Pt is placed on bowel rest and given
parenteral nutrition and miralax
Hospital Course: Days 6 - 7
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Pt develops rash on face on evening of HD6
In the morning, he syncopizes is found to be
hypotensive (SBP 80s) and bradycardic (50s)
Started on broad spectrum abx –
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Vanco, Imipenem and Cipro
Transferred to the ICU; started on pressors
Exam
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VS: T 37.4 HR 114 BP 105/60 RR 24 99% 2L
GEN: wdwn man uncomfortable, rigoring
HEENT: EOMI, small vesicular lesions
scattered on face and neck, neck supple
LUNGS: tachypneic, CTAB
CV: tachy, regular, no m/r/g
EXT: cool extremities, trace edema
SKIN: scattered vesicles on face, chest, back
upper arms, upper thighs
Example of Vesicles
Laboratory Data
3.84
33
35
142 118 35
4.1 20 1.4
AST 588 ALT 518
Alk Phos 197 T bili 2.4
Amylase 476 Lipase 413
Vesicle Swab FA: + VZV
Serum VZV PCR: 4 million copies
Diagnosis:
Disseminated VZV
with Visceral Involvement
Varicella Zoster Virus
in Immunocompromised Host
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Primary VZV infection
Herpes Zoster
Multiple involvement of herpes zoster
Disseminated VZV
Visceral involvement
CNS involvement
Rare Triad: Hyponatremia, abdominal pain
and disseminated cutaneous VZV
Epidemiology
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17-50% of BMT patients are expected to
develop zoster in their post transplant course
Approx. 3.6% of those develop visceral VZV
Disseminated zoster occurs in ~2.6% of
PBSCT
The triad of hyponatremia, abdominal pain,
and disseminated zoster has been reported in
8 cases, mostly among BMT patients
Case Reports
Ref Age/Sex
Primary
Disease
TX
Clinical sx
Day
TX
Outcome
1
57/M
CML
Allo BMT
Abd pain/Ileus /
low Na
9
Acyclovir/
valacyclovir
recovered
2
61/F
NHL
Auto SCT
Abd pain/
low NA
10
Acyclovir
died day 10
3
38/M
CML
Allo unrelated
SCT
Low Na/abd
pain/ileus
10
Acyclovir/ IVIG
recovered
3
32/F
ALL
Allo sib SCT
abd pain/ileus,
low Na
7
Acyclovir/ IVIG
recovered
13
Acyclovir
recovered
4
19/F
ALL
Allo unrelated
Low Na/Abd
pain/hepatitis/
pancreatitis
7
65/F
NHL
CHOP/XRT
Abd pain/
hyponatremia
6
Acyclovir
recovered
8
?
NHL
Chemo/XRT
Ileus/abd pain/
hyponatremia
?
None
recovered
9
50/F
AML
Auto SCT
Abd pain/vomit/
low Na/ hepatitis
7
Acyclovir
recovered
Case: Therapy and Outcome
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Pt was started on high dose acyclovir at
10mg/kg IV q8H
He was treated for 12 days IV and then
transitioned to PO valacyclovir
Lesions have scabbed over, Na is corrected,
no further abdominal pain.
Still with fevers and mild elevation of
transaminases.
VZV PCR Copies and Log10
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HD6:
HD12:
HD18:
HD22:
HD26:
PCR
LOG10
4,000,000
1,500,000
8400
4300
7600
6.6
6.2
3.9
3.6
3.9
Summary
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VZV is a common infection in transplant
patients
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Its manifestations vary from shingles to
fulminant hepatic failure
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Think VZV with hyponatremia and abdominal
pain in the right immunocompromised host
References
1. Szabo, Horvath, Seimon and Hughes. Inappropriate antidiuretic hormone secretion, abodminal pain and
disseminated varicella zoster virus infection: an unusual triad in a patient 6 months post mini-allogeneic
peripheral stem cell tranplant for chronic myeloid leukemia. BMT 2000;26:231-3.
2.McIlwaine, Fitzsimons and Soutar. Inappropriate antidiuretic hormone secretion, abdominal pain and
disseminated varicella zoster virus infection: an unusual and fatal triad in a patient 13 months post Rituximab
and autologous SCT. Clin. Lab Haem 2001;23:253-254.
3. Au, Ma, Cheng, Ooi, and Lie. Disseminated zoster, hyponatremia, severe abdominal pain and leukemia
relapse: recognition of a new clinical quartet after BMT. British J of Dermatology 2003; 149: 862-5.
4. Rau et al. Triad of severe abdominal pain, inappropriate antidiuretic hormone secretion, and disseminated
varicella-zoster virus infection preceeding cutaneous manifestations after hematopoietic stem cell
transplantation: Utility of PCR for early recognition and therapy. Ped Infect Dis J 2008; 27(3):265-8.
5. Kim et al. Factors influencing varicella zoster virus infection after allogeneic peripheral blood stem cell
transplantation: low-dose acyclovir prophylaxis and pre-transplant diagnosis of lymphoproliferative disorders.
Trans Infectious Disease 2008; 10: 90-98.
6. Shiley and Blumberg. Herpes viruses in Transplant recipients: HSV, VZV, Human herpes viruses and EBV.
Infect Dis Clin N Am 2010; 24: 373-93.
7. Ohara et al. Abdominal pain and syndrome of inappropriate antidiuretic hormone secretion as a manifestation
of visceral varicella zoster virus infection in a patient with Non Hodgkins Lymphoma. Am J Hematology 2006.
8. Ingraham, Estes, Bern, DeGirolami. Disseminated varicella-zoster infection with the syndrome of inappropriate
antidiuretic hormone. Arch Intern Med 1983; 143(6):1270-1.
9. Vinzio et al. Severe abdominal pain and inappropriate antidiuretic hormone secretion preceeding varicellazoster virus reactivation 10 months after autologous stem cell transplanation for acute myeloid leukaemia.
BMT 2005; 35:525-7