animal lovers and HIV BHIVA oct2010

10/14/2010
HIV and the animal lover
Which of these does not appear in the
book of Deuteronomy?
• The swine also because it divideth the hoof but
cheweth not the cud shall be unclean to you, ye
shall not eat anything that dieth of itself
• Thou shalt give it unto the stranger that is in thy
gates, that he may eat it or thou mayest sell it
unto an alien
• Mosteth of the egg production in this beloved
nation is, bereftly, diseaseth with the fatal
salmonella infection
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10/14/2010
The famous and their pets: which one
is the odd one out?
• Jim Carey
Houston the iguana
• Richard Gere
Magic the hamster
• George Clooney
Max the pot-bellied pig
• Angelina Jolie
Harry the rat
Odd people have odd pets
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10/14/2010
HIV and the animal lover
• It is estimated that there are some 1870
micro-organisms pathogenic for humans.
• Of these 560 emerged in the last 30 years
• 67% of these can be transmitted between
vertebrate animals and man = ZOONOTIC
Animals may be dead, sick or well!
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10/14/2010
Case history 1
• Diagnosed HIV 2005 when admitted with PCP
(CD4 27)
• Started on NVP/TDF/FTC
• Poorly adherent - CD4 89 and VL 16000 at last
visit 4m before presentation
• Plan to switch combination pending resistance
results
• On dapsone
Case history 1
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Farmer all his life
Married, partner -ve
Non-smoker, no travel
BCG’d and no TB contact
Farm has horses, goats, chickens, turkeys, and
sheep
• Also domestic rabbits and cats
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10/14/2010
Case history 1
• 5w increasing illness:
– Breathlessness
– Cough with haemoptysis
– Fevers/rigors
– Weight loss
• WCC 19.7, CRP 214
• Other bloods relatively normal
Admission CXR
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10/14/2010
What is the most likely diagnosis?
• Pneumococcus
• TB
• Cryptococcus
• Staph. aureus
Initial treatment and investigations
• Started on Ceftriaxone IV
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Legionella/pneumococcal antigen tests –ve
Sputum PCP-PCR –ve
CRAG –ve and CMV-PCR –ve
Mycoplasma IgM –ve
Arterial gases OK
Blood cultures ‘diphtheroids’ and likely
contaminant
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10/14/2010
Sputum microscopy
Gram and ZN
Watanabe H et al J Infect Chemother 2000; 6:229–232
What is the most likely diagnosis?
• TB
• Nocardia
• Anthrax
• Coxiella (Q fever)
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10/14/2010
Case history 1
• Over next 2 days:
– Increasing respiratory symptoms of chest pain,
breathlessness and haemoptysis
– Increasingly toxic and systemically sick
– WCCt ↑ to 25.4 and CRP to 326
– pO2 ↓
• Clarithromycin IV added
3 days after admission
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10/14/2010
5 days sputum culture results
What do you think the diagnosis is?
• Psittacosis
(birds/turkeys)
• Rhodococcus equi
(horses)
• Pasteurella multocida
(sheep/rabbits)
• Coxiella burnettii
(sheep)
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10/14/2010
Rhodococcus equi
Gram +ve coccobacillus
Weakly AFB +ve
Culture – salmon pink
TB like presentation
Rhodococcus
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Often diagnosed late when sick
80% lung affected
Mimics TB and AFB +ve so mistreated
Lab think blood culture = diphtheroids and
contaminant (+ve in >80%) = chuck
• Sputum culture - salmon colonies not visible
till 4d (>80% sputum cultures +ve) = chucked
• ‘Standard’ pneumonia treatment insufficient
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10/14/2010
Rhodococcus
• Most cases in HIV - CD4 <100
• Significant mortality (55%)
• 2/3rds no animal contact but remember equi =
horse = foals especially = soil
• Relapses and extrapulmonary disease common
• Acquisition inhalation (ingestion/contact)
• Difficult to eradicate requiring long course of
treatment
Lung biopsy
• Typical histopathology on lung bx
– Malakoplakia and Michaelis-Gutman bodies
Yamshchikov A et al Lancet Infect Dis 2010; 10: 350–359
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10/14/2010
Radiographic Findings – anything!
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Nodule(s) or pneumonia most common
Upper lobe preference
Often cavitation/abscess development
Cavities are thick walled and may demonstrate airfluid levels
• Pleural effusion/empyema, pneumothorax or direct
chest wall involvement may complicate
Looks like TB but MORE aggressive
Nodules and patchy consolidation
Moretti F et al AIDS. 16(10):1440-1442
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10/14/2010
Pleural effusion/consolidation
Treatment
• Penicillin and cephalosporin resistant
• Use 2-3 antibiotics; 2m IV then 4m oral
• Preferred:
– Rifampicin, quinolone, clarithromycin,
aminoglycosides, vancomycin,
meropenem/imipenem, linezolid
• Example:
– VANC + meropenem, rifampicin or aminoglycoside
• Surgery sometimes for abscesses/matted nodes
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10/14/2010
Take home message
• Animal contact history important
– Domestic, farm, or wild?
– Scratch, ingestion, inhalation, insect bite?
• Think - unusual pathogens
• Remember – failure to respond may = unusual
pathogens
Case history 2
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66y old postman, diagnosed 1996
Well controlled but CD4 never >110 VL <40
On ATAZ/r/TDF/FTC and atovaquone
Normally fit and well:
– Hypertension, high lipids, NIDDM (diet
controlled), and oesophageal reflux
– On ramipril, pravastatin
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10/14/2010
Case history 2
• Developed two irritating lumps on the back of
the hand over 3-4w
• No erythema, pus, fluctuance, or scratches
evident
• Followed by fevers/sweats and painful armpit
• Tender R epitrochlear gland and axillary glands
• No lymphangitis visible
Case history 2
• GP prescribed co-amoxiclav
• Worsening fever with rigors and admitted to
hospital
• Bloods unremarkable:
– WCCt 6.4 normal differential
– CRP 19
– LFT’s mildly deranged (ALT 41 Alk Phos 106)
• CXR normal
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10/14/2010
Case history 2
• Travelled to southern Europe
• Keen gardener
• At home:
– ‘Reginald’, a Columbian Rainbow boa
– ‘Teabag’ and ‘Marmite’, two kittens
– Tropical fish tank: recent acquisition of dwarf frogs
– Several lizards
– Aviary with budgerigars and canaries
– Prize-winning parakeet called ‘Joey’
3-4 w increasing in size
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10/14/2010
What is the most likely diagnosis?
• KS
• Cryptococcus
• Syphilis
• None of these
Progress
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CRAG –ve, RPR –ve
Swab for microscopy and culture NAD
Blood cultures -ve
MR scan NAD
Serology for all funny pathogens sent
Biopsy
– Histology staining
– ZN and mycobacterial culture
• Co-amoxiclav given
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10/14/2010
Skin biopsy histology
Warthin-Starry stain
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10/14/2010
What is the diagnosis?
• Mycobacterium marinum
(fish tank)
• Bartonella henselae
(kittens)
• Pasteurella multocida
(rabbits)
• Sporothrix schenckii
(gardening)
Bartonellosis in HIV
• 2 organisms: B. henselae and B. quintana
• One-third of cats bacteraemic and
asymptomatic
– > in kittens
• Culture challenging
• Diagnosis through histology and serology
(takes time)
• Gram –ve, ZN –ve
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10/14/2010
Bartonellosis in HIV
• Nearly always skin involvement
• Several types:
– Subcutaneous nodules +/- ulceration
– KS like lesions – plaques or nodules
• Single or numerous
• Systemic symptoms indicate systemic disease
– Can be found anywhere
– Lung, gut, lymph-nodes, liver (peliosis hepatitis),
spleen, bone, CNS, heart etc
Skin and bone lesions
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10/14/2010
Bartonellosis in HIV
• Treatment with macrolides, doxycycline,
rifampicin or co-trimoxazole
• Duration 3m but depending on degree of
immunocompromise
• Herxheimer-like reaction can occur
Take home message
• Biopsy early
• Inform surgeons and histopathologists in advance
if specific stains (ZN, fungal, Warthin-Starry etc)
• Animal history important
• Some patients may keep very odd animals as pets
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10/14/2010
Case history 3
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Young 34y old man
Diagnosed HIV +ve 9m
Born and bred rural Zimbabwe → UK 2005
Presentation with pulmonary TB
– CD4 150
– Fully sensitive TB treated 6m QUAD
• On EFV/TDF/FTC for 8m
• Now CD4 340 VL <40
Case history 3
• Seen in OPD and c/o feeling muddled and ‘not
right’
• Thought to be due to EFV s/e
– Switched to FOS/r
• 3d later → grand-mal seizure and admitted
– No focal signs
– LP performed: no cells, protein 0.64, glucose ratio
normal
– Standard bloods unremarkable
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10/14/2010
CT with contrast
Case history 3
• Referred to neurosurgeon with diagnosis of
either toxoplasmosis or primary CNS
lymphoma
• Planned for biopsy
• ID heard and told them 2w of anti-toxoplasma
treatment, wait + further tests!
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10/14/2010
What do you think the diagnosis is?
• Toxoplasmosis
• Primary CNS lymphoma
• TB
• Cryptococcoma
Case history 3
• Ears/sinuses normal
• Additional investigations:
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Toxoplasma serology +ve
CRAG –ve
CSF RPR –ve
PCR tests for EBV, HS, VZV, JC, CMV all –ve
• CXR – normal
• Blood cultures –ve
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10/14/2010
A diagnostic procedure was
performed
Answer available in 30 minutes!!
Was it?
• Further imaging
• Another blood test
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10/14/2010
Thighs!
What do you think the diagnosis is?
• Schistosomiasis
• Gnathostomiasis
• TB
• Cysticercosis
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10/14/2010
Progress
• Review of imaging suggested
neurocysticercosis:
• Treatment:
– Albendazole
– Dexamethasone
– Praziquantel
– Anticonvulsants
Serology strongly +ve for Cysticercosis
Non-HIV sensitivity and specificity >95% but less so for single and/or
calcified lesions
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10/14/2010
Neurocysticercosis
• Taenia solium
– Pork Tapeworm
CDC Division of Parasitic Diseases www.dpd.cdc.gov
Neurocysticercosis
• Inside brain tissue (parenchymal)
• Outside brain tissue (extraparenchymal)
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Ventricles
Subarachnoid space
Spine
Eye
• Develop over 3-8w but not for 3-5y do they cause
problems
• Presentation = where they are
– Fits if in the brain
– Hydrocephalus if outside usually
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10/14/2010
Imaging
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CT very good – MR for smaller cysts
Usually 5-20mm in size (multiple > single)
Hypodense initially but may be hyperdense!
Oedema = contrast enhancement usual
• Cigar shaped cysts in muscle characteristic
Neurocysticercosis in HIV
• Uncertain whether > in HIV
• Possible ‘racemose or proliferating’ form more
common
• Difficult to diagnose because of wide
differential
• CD4 helpful as CC more likely with higher CD4
• Cases on record developing as IRS
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10/14/2010
Neurocysticercosis in HIV
• Tissue X-Ray and early serology may save
brain biopsy post 2w anti-toxoplasmal therapy
• Serology less reliable in HIV but still likely +ve
• Consider empirical antihelminthic therapy if
MR typical?
Take home messages
• ↑ likelihood of ‘unusual’ causes with ↑
migration from endemic countries
• Animal contact history important
• Domestic, farm, or wild?
• Odd people keep odd animals as pets
• Follow lead – type of contact? (scratch,
ingestion, inhalation etc)
• Always consider the unusual pathogens
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