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ID Fellows Case Conference

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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ID Fellows Case Conference

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  1. ID Fellows Case Conference August 25, 2010 Lindley Barbee MD, MPH

  2. A classic presentation of an uncommon disease …except among transplant patients.

  3. An Uncommon Presentation of a Common Disease

  4. Case 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

  5. Background History • PMH • Gout • Benign adenoma of brain s/p resection 2000 • Pituitary adenoma • Melanoma s/p excision • TURP for BPH • Family History • Father died of colon CA • Mother died of liver CA • Medications • Allopurinol • Levothyroxine • Cabergoline • Dexamethasone 0.5mg • Benadryl prn • Marinol prn • Compazine prn • Ambien prn

  6. 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 -

  7. Case 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.

  8. Admission Data VS: T 36.4 HR 80 BP 140/78 RR 18 100% RA 121 | 88 | 16 / AST 61 ALT 61 AlkPhos 121 4.0 | 21 | 0.8 \ 2.99 \ / 54 Serum Osms 250 / 38 \ Una 53 75% polys 18% lymphs

  9. Hospital Course: Days 2 - 4 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

  10. Hospital Course: Days 6 - 7 • 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 – • Vanco, Imipenem and Cipro • Transferred to the ICU; started on pressors

  11. Exam 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

  12. Example of Vesicles

  13. Laboratory Data 3.84 33 AST 588 ALT 518 35 Alk Phos 197 T bili 2.4 142 118 35 Amylase 476 Lipase 413 4.1 20 1.4 Vesicle Swab FA: + VZV Serum VZV PCR: 4 million copies

  14. Diagnosis: Disseminated VZV with Visceral Involvement

  15. Varicella Zoster Virusin Immunocompromised Host 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

  16. Epidemiology 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

  17. Case Reports

  18. Case: Therapy and Outcome 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.

  19. VZV PCR Copies and Log10 PCR LOG10 • HD6: 4,000,000 6.6 • HD12: 1,500,000 6.2 • HD18: 8400 3.9 • HD22: 4300 3.6 • HD26: 7600 3.9

  20. Summary • VZV is a common infection in transplant patients • Its manifestations vary from shingles to fulminant hepatic failure • Think VZV with hyponatremia and abdominal pain in the right immunocompromised host

  21. 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 varicella-zoster virus reactivation 10 months after autologous stem cell transplanation for acute myeloid leukaemia. BMT 2005; 35:525-7

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