Reminder of important clinical lesson
CASE REPORT
Initial diagnosis of HIV/AIDS in a 56-year-old man with non-healing forearm lesion Heidi J Zapata, Merceditas Villanueva, Sheela Shenoi
Department of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, USA Correspondence to Dr Heidi J Zapata, [email protected]
SUMMARY A 56-year-old Hispanic man with no significant medical problems presented with a 2-month history of a nonhealing right forearm lesion that progressed despite several courses of empiric antibiotics. The patient underwent incision and drainage. Warthin-Starry stain with immunohistochemistry testing diagnosed bacillary angiomatosis secondary to Bartonella quintana. Subsequently, the patient was diagnosed with HIV, with a CD4 count of 68 cells/mm3, and a HIV viral load of 47, 914 copies/mL. The patient was treated with doxycycline and started on antiretroviral therapy. The lesion has resolved and he has had no recurrence after 16 months of treatment. BACKGROUND Bacillary angiomatosis (BA) was first described in a patient with AIDS, and is most common in this population.1 It has also been described in patients with transplant and other immunocompromised hosts and rarely in immunocompetent hosts.2 While BA can present as a visceral disease, skin lesions are the most common clinical manifestation of the disease, ranging from 55% to 90%.3 The lesions can vary from being solitary or dispersed, and can vary in colour and appearance. Bartonellosis needs to be considered when approaching patients with atypical cutaneous lesions that are inadequately responding to empiric antibiotics, with appropriate testing for possible underlying HIV infection.
CASE PRESENTATION
To cite: Zapata HJ, Villanueva M, Shenoi S. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013201184
A 56-year-old Hispanic man with no significant medical history noted a small right forearm lesion. The lesion developed progressive erythema and swelling prompting evaluation at a community outpatient clinic. He was diagnosed with cellulitis and was prescribed cephalexin and trimethoprim-sulfamethoxazole. After 3 weeks with no improvement in the lesion, the patient was admitted to Yale-New Haven Hospital, and started on vancomycin for presumptive cellulitis. The admission records described the right forearm to have a fluctuant 2×4 inches lesion that was tender, erythematous, swollen and warm. The patient underwent incision and drainage (I&D) of the lesion. The cultures grew coagulase negative Staphylococcus. As the patient was also noted to have right-sided cervical lymphadenopathy, a CT scan of his neck was performed which showed multiple prominent bilateral cervical level IIA and IIB
Zapata HJ, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-201184
lymph nodes, the largest of which was 2.3×2.5 × 3.4 cm on the right, medial to the sternocleidomastoid, with a possible necrotic/cystic component along the inferior aspect. Fine-needle aspiration of a lymph node revealed macrophages and abundant acute inflammation, but no organisms were noted on acid–fast bacilli (AFB) and Grocott Methenamine Silver stains. A PPD was read as negative. The patient was discharged on oral clindamycin to complete a course of 7 days for presumptive cellulitis with reactive lymphadenopathy. The patient was readmitted after he presented to the Hand Clinic 4 weeks later with continued pain, swelling and drainage from the previous I&D site. On examination the patient was febrile (38.5°C) and haemodynamically stable. He had a 1 cm rightsided cervical lymph node that was mobile and nontender. His right forearm was noted to have moderate warmth erythema, swelling and serous drainage at the I&D site. His laboratory studies revealed a total white cell count (WCC) 5.3 cells/mm3 (79% neutrophils, 15% lymphocytes, 5% monocytes and 1% eosinophils), aspartate aminotransferase 15 (Ref range 0–34 U/L), alanine aminotransferase 19 (Ref range 0–34 U/L), alkaline phosphatase 47 (Ref range 40– 115 U/L), an elevated C reactive protein 62.9 mg/L (Ref range 0.1–3.0 mg/L) and an erythrocyte sedimentation rate 104 mm/h (Ref range 0–20 mm/h). MRI of the right forearm revealed a heterogeneous infiltrative phlegmon in the extensor compartment of the forearm without a discrete abscess collection (figure 1). The patient underwent exploration and debridement of the right forearm with findings of an abundance of chronic appearing fibrinous amorphous material. Gram stain revealed 3+WCCs, and no organisms. Fungal and AFB stains were negative. The patient was started on cefazolin pending further studies. The Infectious Disease (ID) service was consulted at this time and additional history was obtained. The patient was originally from Mexico and had immigrated to the USA in 2003 with no subsequent return visits. The patient denied past or present tobacco or illicit drug use. His last sexual activity was in 2003 with his wife, who had remained in Mexico. He had previous heterosexual contacts prior to marriage. The patient denied homelessness. He worked at a pizzeria, slicing vegetables and cheese. He did not have any pets and specifically had no exposures to cats. He denied any recent history of insect bites. He described night sweats and a 25-pound weight loss that began months prior to the forearm lesion. 1
Reminder of important clinical lesson OUTCOME AND FOLLOW-UP
Figure 1 MRI of the right forearm lesion showing heterogeneous infiltrative phlegmon in the extensor compartment of the forearm, as shown by arrow.
INVESTIGATIONS The ID service recommended HIV testing which showed a positive HIV ELISA with confirmatory western blot. The CD4 count was 68 cells/mm3 and viral load (VL) 47 914 copies/mL. Warthin-Starry stain was requested of the operative specimen obtained on the second admission. Bartonella henselae serologies were sent. While in the hospital the patient subsequently developed a large nodular lesion at the biceps with patchy-associated erythema that according to him was similar to the first lesion, as shown in figure 2. A CT scan of the abdomen and pelvis was conducted to evaluate for peliosis.
Pathology from the right forearm lesion showed acute and chronic inflammation. Inflamed reactive fibrous tissue was noted with skeletal muscle bundles and several fragments of vascular tissue with a dense neutrophilic infiltrate and karyorrhectic debris. Warthin-Starry staining revealed numerous clumps of organisms, consistent with Bartonella infection. Immunostaining with a B henselae-specific antibody was negative. However, a polyclonal antibody directed against Bartonella quintana co-localised with the organisms seen on the Warthin-Starry stain (figure 3). Although, the polyclonal antibody does cross react with B henselae, these findings support the presence of B quintana, consistent with a diagnosis of HIV-associated BA. Several weeks later, the B henselae IgG was positive with a titer of 1:256. A CT scan of the abdomen and pelvis showed mild hepatomegaly and a normal-sized spleen. The patient was discharged to complete a course of doxycycline. A few weeks later, he was successfully initiated on antiretroviral therapy (ART) as an outpatient with a fixed dose combination of tenofovir, emtricitabine and efavirenz. He was also prescribed prophylaxis for Mycobacterium avium complex (MAC) and Pneumocystis jirovecii pneumonia (PJP). Six months later his CD4 was 283 cells/mL and HIV VL was
CASE REPORT
Initial diagnosis of HIV/AIDS in a 56-year-old man with non-healing forearm lesion Heidi J Zapata, Merceditas Villanueva, Sheela Shenoi
Department of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, USA Correspondence to Dr Heidi J Zapata, [email protected]
SUMMARY A 56-year-old Hispanic man with no significant medical problems presented with a 2-month history of a nonhealing right forearm lesion that progressed despite several courses of empiric antibiotics. The patient underwent incision and drainage. Warthin-Starry stain with immunohistochemistry testing diagnosed bacillary angiomatosis secondary to Bartonella quintana. Subsequently, the patient was diagnosed with HIV, with a CD4 count of 68 cells/mm3, and a HIV viral load of 47, 914 copies/mL. The patient was treated with doxycycline and started on antiretroviral therapy. The lesion has resolved and he has had no recurrence after 16 months of treatment. BACKGROUND Bacillary angiomatosis (BA) was first described in a patient with AIDS, and is most common in this population.1 It has also been described in patients with transplant and other immunocompromised hosts and rarely in immunocompetent hosts.2 While BA can present as a visceral disease, skin lesions are the most common clinical manifestation of the disease, ranging from 55% to 90%.3 The lesions can vary from being solitary or dispersed, and can vary in colour and appearance. Bartonellosis needs to be considered when approaching patients with atypical cutaneous lesions that are inadequately responding to empiric antibiotics, with appropriate testing for possible underlying HIV infection.
CASE PRESENTATION
To cite: Zapata HJ, Villanueva M, Shenoi S. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013201184
A 56-year-old Hispanic man with no significant medical history noted a small right forearm lesion. The lesion developed progressive erythema and swelling prompting evaluation at a community outpatient clinic. He was diagnosed with cellulitis and was prescribed cephalexin and trimethoprim-sulfamethoxazole. After 3 weeks with no improvement in the lesion, the patient was admitted to Yale-New Haven Hospital, and started on vancomycin for presumptive cellulitis. The admission records described the right forearm to have a fluctuant 2×4 inches lesion that was tender, erythematous, swollen and warm. The patient underwent incision and drainage (I&D) of the lesion. The cultures grew coagulase negative Staphylococcus. As the patient was also noted to have right-sided cervical lymphadenopathy, a CT scan of his neck was performed which showed multiple prominent bilateral cervical level IIA and IIB
Zapata HJ, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-201184
lymph nodes, the largest of which was 2.3×2.5 × 3.4 cm on the right, medial to the sternocleidomastoid, with a possible necrotic/cystic component along the inferior aspect. Fine-needle aspiration of a lymph node revealed macrophages and abundant acute inflammation, but no organisms were noted on acid–fast bacilli (AFB) and Grocott Methenamine Silver stains. A PPD was read as negative. The patient was discharged on oral clindamycin to complete a course of 7 days for presumptive cellulitis with reactive lymphadenopathy. The patient was readmitted after he presented to the Hand Clinic 4 weeks later with continued pain, swelling and drainage from the previous I&D site. On examination the patient was febrile (38.5°C) and haemodynamically stable. He had a 1 cm rightsided cervical lymph node that was mobile and nontender. His right forearm was noted to have moderate warmth erythema, swelling and serous drainage at the I&D site. His laboratory studies revealed a total white cell count (WCC) 5.3 cells/mm3 (79% neutrophils, 15% lymphocytes, 5% monocytes and 1% eosinophils), aspartate aminotransferase 15 (Ref range 0–34 U/L), alanine aminotransferase 19 (Ref range 0–34 U/L), alkaline phosphatase 47 (Ref range 40– 115 U/L), an elevated C reactive protein 62.9 mg/L (Ref range 0.1–3.0 mg/L) and an erythrocyte sedimentation rate 104 mm/h (Ref range 0–20 mm/h). MRI of the right forearm revealed a heterogeneous infiltrative phlegmon in the extensor compartment of the forearm without a discrete abscess collection (figure 1). The patient underwent exploration and debridement of the right forearm with findings of an abundance of chronic appearing fibrinous amorphous material. Gram stain revealed 3+WCCs, and no organisms. Fungal and AFB stains were negative. The patient was started on cefazolin pending further studies. The Infectious Disease (ID) service was consulted at this time and additional history was obtained. The patient was originally from Mexico and had immigrated to the USA in 2003 with no subsequent return visits. The patient denied past or present tobacco or illicit drug use. His last sexual activity was in 2003 with his wife, who had remained in Mexico. He had previous heterosexual contacts prior to marriage. The patient denied homelessness. He worked at a pizzeria, slicing vegetables and cheese. He did not have any pets and specifically had no exposures to cats. He denied any recent history of insect bites. He described night sweats and a 25-pound weight loss that began months prior to the forearm lesion. 1
Reminder of important clinical lesson OUTCOME AND FOLLOW-UP
Figure 1 MRI of the right forearm lesion showing heterogeneous infiltrative phlegmon in the extensor compartment of the forearm, as shown by arrow.
INVESTIGATIONS The ID service recommended HIV testing which showed a positive HIV ELISA with confirmatory western blot. The CD4 count was 68 cells/mm3 and viral load (VL) 47 914 copies/mL. Warthin-Starry stain was requested of the operative specimen obtained on the second admission. Bartonella henselae serologies were sent. While in the hospital the patient subsequently developed a large nodular lesion at the biceps with patchy-associated erythema that according to him was similar to the first lesion, as shown in figure 2. A CT scan of the abdomen and pelvis was conducted to evaluate for peliosis.
Pathology from the right forearm lesion showed acute and chronic inflammation. Inflamed reactive fibrous tissue was noted with skeletal muscle bundles and several fragments of vascular tissue with a dense neutrophilic infiltrate and karyorrhectic debris. Warthin-Starry staining revealed numerous clumps of organisms, consistent with Bartonella infection. Immunostaining with a B henselae-specific antibody was negative. However, a polyclonal antibody directed against Bartonella quintana co-localised with the organisms seen on the Warthin-Starry stain (figure 3). Although, the polyclonal antibody does cross react with B henselae, these findings support the presence of B quintana, consistent with a diagnosis of HIV-associated BA. Several weeks later, the B henselae IgG was positive with a titer of 1:256. A CT scan of the abdomen and pelvis showed mild hepatomegaly and a normal-sized spleen. The patient was discharged to complete a course of doxycycline. A few weeks later, he was successfully initiated on antiretroviral therapy (ART) as an outpatient with a fixed dose combination of tenofovir, emtricitabine and efavirenz. He was also prescribed prophylaxis for Mycobacterium avium complex (MAC) and Pneumocystis jirovecii pneumonia (PJP). Six months later his CD4 was 283 cells/mL and HIV VL was
