Hilary Ong, MD Children’s National Medical Center

Case: 16 yo male with a history of asthma and HIV, non complaint with therapy, presenting with a chronic cough for the past few months. It seems to wax and wane, but, was treated 2 weeks prior for asthma exacerbation with short term relief. He was afebrile but in moderate respiratory distress upon initial exam with scattered crackles and wheezes on exam. His work of breathing improved somewhat with albuterol but remained persistently tachycardic with borderline hypoxemia.

Here’s How You Answered Our Questions:

Discussion:

As emergency medicine physicians, we are often oblivious to chronic/monitoring labs. HIV is one of those conditions that requires extensive monitoring, but also, requires some obscure testing that is unfamiliar to many of us. This was a great case to highlight just a few of the many potential HIV tests that are available to us as providers as we got a flavor for in the first poll question. Dr. Ong graciously walked us through the “HIV tests for dummies” handbook. HIV PCR as well as Ag/Ab screen are useful for primary diagnosis, but aside from that, do not have much utility in the acute setting. Most importantly in an acute setting for a patient known to have HIV, are the CD4 count (aka Lymphocyte subset panel #3) and Viral load. Hopefully this helps for the future as answers were all over the place (but a majority for CD4 and VL!).

The third poll question was slightly more straightforward, yet, created a great discussion. For this patient, Dr. Root was spot on. A patient who has persistent tachycardia in the setting of a potential infection with some improvement in respiratory status should be watched closer. Whether that closer means a longer LOS in the ED or admission may be debatable with the limited amount of information we have. Unless clear improvement in vital signs are made as well as solidified follow up in place with a historically non compliant patient, one would be hard pressed to discharge this patient home. Drs. Koutroulis and Chapman reiterated that point as well as the entire room.

The second poll question gave me the most insight into understanding clinical practice reasoning. Dr. Ong taught us that one can usually gauge the severity of disease/compliance with the patients medication regimen. In an otherwise compliant patient, Bactrim is usually the only prophylactic antibiotic (PJP). When you see levofloxacin (MAC) and Fluconazole (Crytococcus) added on, it usually means poor compliance/severe disease as was the case with our patient. Nearly everyone agreed at a minimum to cover for CAP and Atypicals with Ceftriaxone and Azithromycin. Bactrim for PJP (treatment dose) was up for debate as well as Fluconazole for fungals (given chronicity of symptoms). The group seemed variable in terms of how aggressive they wanted to be upfront. Dr. Cahill felt that this patient did not fit the typical illness script for PJP, thus, deferred Bactrim at this time. Dr. Isbey similarly felt MRSA pneumonia was much less likely and deferred Vancomycin at this time. Dr. Koutrolis mentioned he would seriously consider Fluconazole given the chronicity of symptoms. None the less, this patient was being admitted and could always have therapy broadened if initially unresponsive.

Denouement:

Radiology read the CXR as a potential early LUL infiltrate. The patient was found to have CD4 <50 with HIV viral load >150,000. Infectious Disease was consulted from Emergency Department to aid in guidance on appropriate antimicrobial therapy.

Given patient’s overall history and exam, ID recommended to treat for community acquired
pneumonia with ceftriaxone and azithromycin. The clinical exam was less concerning for PJP
pneumonia or MAC/TB infection. The patient was admitted for hypoxia secondary to
pneumonia, and observed for immune reconstitution inflammatory syndrome while his HAART was being reinitiated.

https://www.ncbi.nlm.nih.gov/pubmed/21441488

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