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NYU Medical Grand Rounds Clinical Vignette

NYU Medical Grand Rounds Clinical Vignette. Mark H. Adelman, M.D. PGY-2 2/19/13. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. 43 year old man presents with headache, neck pain for approximately one week.

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NYU Medical Grand Rounds Clinical Vignette

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  1. NYU Medical Grand Rounds Clinical Vignette Mark H. Adelman, M.D. PGY-2 2/19/13 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 43 year old man presents with headache, neck pain for approximately one week

  3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Diagnosed with HIV in 2002, on HAART until he lost insurance in 2009 • Doing well until 10 days prior to admission, felt like there was “fluid swishing in my ears” • Four days later, vomited multiple times, began to experience headache and neck stiffness

  4. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Presented to ER, head CT, left AMA prior to complete evaluation • Headache, neck stiffness, nausea/vomiting continued • No relief with naproxen, ibuprofen • Returned to ER for unremitting headache

  5. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical History: • Bipolar II • Past Surgical History: • Hernia repair as a child • Social History: • No tobacco. Rare alcohol. Infrequent intranasal cocaine, semi-weekly cannabis use • Sex with men • Family History: • noncontributory • Allergies: • No known drug allergies • Medications: • Naproxen, ibuprofen as needed

  6. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • General: Well appearing man, alert, in mild distress • Vital Signs: T: 97.5, BP: 125/78, HR: 55, • RR: 16, O2 sat: 96%RA • Neck pain with flexion/extension • Remainder of Physical Exam was normal

  7. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CBC: Hemoglobin 16.7 • Remainder of CBC was within normal limits • Basic metabolic panel: Potassium 3.5 • Remainder of basic was within normal limits • Hepatic panel: ALT 74 • Remainder of hepatic panel was within normal limits

  8. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CSF • Opening pressure 37 • 12 WBCs (84% lymphocytes, 16% monocytes) • Protein 64 • India ink, culture, cryptococcal antigen, HSV PCR pending • Blood cultures: pending • CD4 count and HIV-1 RNA: pending

  9. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Chest X-Ray: 1cm nodular opacity in right midlung • CT head: no acute intracranial findings

  10. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working or Differential Diagnosis • Cryptococcal meningitis • Viral meningitis • HSV encephalitis

  11. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 1: • Amphotericin, flucytosine. Acyclovir • Hospital Day 2: • CD4 count 52 (5%). HIV-1 RNA 28,400. • Trimethoprim-sulfamethoxazole • Repeat lumbar puncture

  12. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 3: • CSF India ink stain + for cryptococcus • CSF cryptococcal antigen + (1:8,192) • Serum cryptococcal antigen + (1:32,768) • CT chest: Multiple round, nodular opacities right lower lobe. Mediastinal, pretracheal, right hilar lymphadenopathy

  13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 4: • Headache improved • HSV PCR negative. Acyclovir discontinued • HD#1 CSF fungal culture + for cryptococcus • Hospital Days 5-7 • Induced sputum negative for AFB x3 • HD#2 CSF fungal culture + for cryptococcus • Blood cultures + for cryptococcus • Bronchoscopy: BAL, transbronchial lymph node/lung biopsies negative for AFB, + for cryptococcus

  14. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 8: • Repeat LP: opening pressure 36 • Cryptococcal antigen 1:512. Culture negative. VDRL + • IV penicillin G • Hospital days 9-14 • Recurrent headaches • serial LPs until opening pressure 20. Cultures negative • Right occipital lymphadenopathy

  15. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 15 • Amphotericin, flucytosine discontinued • Oral fluconazole started • Hospital Day 16 • Fine needle aspiration of occipital lymph node • Hospital Day 18 • IV penicillin discontinued • FNA + for cryptococcus • Discharged home with virology follow-up in one week

  16. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Disseminated cryptococcosis

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