|
Home Page
Back to Case Histories
Facilities
Complex
Patients
Staff
History
Future
Hospital
Successes
Mission
TB Diagnostics
|
A.G. Holley Hospital
Case
Histories
Case 2
41 year old black male
presented to JMH in 7/98 with a two month history of anorexia, 30 lb wt loss, fevers,
chills and two week history of increasing shortness of breath and enlarging neck mass. He
denied cough or hemoptysis. He had a 15 year history of being HIV (+), diagnosed after
attempting to donate blood, without a history of opportunistic infections or previous
antiretroviral therapy. Upon admission to JMH, a chest x ray showed a right paratracheal
LN enlargement. On physical exam he was found to have a left suppurative anterior cervical
mass. Sputum was AFB (+). An aspirate of the cervical mass was AFB (+). The patient was
started on 4 anti-tuberculous drugs and was discharged to DOT on 7/24/98.Soon after discharge the
patient left to go to Georgia without notifying the health department or taking his TB
medications. He returned to Florida on 9/1/98 and represented to JMH with a two week
history of fever, chills, night sweats, weight loss with a productive cough. Cultures from the previous LN aspirate as well as
sputum were found to be positive for MTB and resistant to INH at 2.0ug/ml, and sensitive
to the rest of the first line medications. Repeat CXR revealed the right paratracheal
lymphadenopathy. Sputums were again AFB (+). The patient was restarted on 4 drugs and
court committed to AGH.
Labs were significant for an elevated uric
acid of 10.2ug/ml, albumin of 3.3, WBC of 10.2k, Hgb of 11.2 and Hct of 34 and plt 334k.
VDRL (-). Toxo IgG was (+), IgM was (-). HIV viral load was 7.5 x 105, CD4
count was 42 CD4% 2%, 0.03 ratio. On admission, he was anergic and PPD (-). Labs were significant for an elevated uric
acid of 10.2ug/ml, albumin of 3.3, WBC of 10.2k, Hgb of 11.2 and Hct of 34 and plt 334k.
VDRL (-). Toxo IgG was (+), IgM was (-). HIV viral load was 7.5 x 105, CD4
count was 42 CD4% 2%, 0.03 ratio. On admission, he was anergic and PPD (-)
Approximately twelve days later the patient developed fever, severe neck pain and the
sudden onset of quadraplegia. Physical exam was significant for no nuchal rigidity
but 2-3/5 strength of all four extremities. A Diagnostic Procedure was performed.
He was started on 100 mg of Decadron x 1 and 10 mg q 6h for one wk, and
progressively tapered over the next 2 mo. In addition he was started on
Pyrimethamine, Sulfadiazine and Cycloserine. HIV viral load was 1.2x103,
5%, 0.08.
He was now able to walk with
full strength of all four extremities. Afebrile, PPD (+). The pyrimethamine and
sulfadiazine were stopped due to lack of usual response. Soon after ARVs are started
in patients with HIV and TB, paradoxical responses may frequently be seen (esp. in
patients with an initially high HIV viral load who experience a marked drop post
ARVs).
(? new category of "Treatment Reactions" in TB patients)
Clinicians should be aware of
this phenomenon although other possibilities for a worsening clinical state must first be
excluded
|
