EB is a 20 year old male with no significant past medical history. He presents to you with a complaint of feeling feverish. He states that for the past 4 weeks he has had a fever to 101.3F (38.5C) every night followed by a drenching sweat. He states that he has diffuse muscle aches and feels fatigued. His review of systems is otherwise negative.
He relates that he had an episode of aseptic meningitis worked up at your institution 2 months ago. At that time he presented with a fever, headache, stiff neck, a sore throat, a transient skin rash and loose stools.
You review the computer and note he was hospitalized for 5 days. He had 2 lumbar punctures and was treated with vancomycin, ceftriaxone and acyclovir and was discharged with the diagnosis of aseptic meningitis, thought to be related to an enterovirus. You review his laboratory reports and note the following:
130 / 105 / 18 / 130 3.8 \ 12.1 / 102
4.5 / 27 / 0.9\ / 32.0 \
Liver enzymes: within normal limits
UA: within normal limits
CSF: protein 60 glucose 30 WBC 60 90L 5P (repeat 24 hours later was unchanged)
Blood cultures x 4 sets (2 sets done 24 hours apart) no growth
CSF culture for bacteria and virus negative
CXR: no infiltrates
CT head without contrast: no evidence of increased intracranial pressure
See questions #1-5
In further evaluating the patient you now do a thorough history. Review of systems is negative for any further complaints except unintended weight loss of 10 pounds over the last 4 weeks. Besides occasional Tylenol® for fever he denies any other medications. EB dropped out of high school and works as a server. He denies any known sick contacts and keeps no pets. He lives in an apartment in Chicago which he shares with a roommate. He denies alcohol or drug use and smokes ½ pack of cigarettes daily. He is single but sexually active and denies any unprotected sexual intercourse. He denies any travel outside the Chicagoland area.
Physical examination reveals:
Vitals: 38.2C P: 108 R: 14 BP 118/68 Wt.: 68 Kg. Ht.: 6 ft 3 inches
HEENT: Discs flat, conjunctivae clear; EAC clear with pearly TMs; nares patent without discharge and no sinus tenderness; teeth in good repair; enlarged tonsils and a white, coated tongue; tiny cervical shoddy LAD; small palpable axillary LNs
LUNGS: CTA HEART: RRR w/o murmurs or gallops
ABDOMEN: scaphoid, normal bowel sounds, soft nontender w/o rigidity, rebound or guarding w/o liver enlargement, palpable spleen tip present
GU: Normal male
EXTREMITIES: w/o clubbing, cyanosis or edema or deformities; without rash.
NEUROLOGIC: intact and nonfocal
You place a PPD, order HIV serology, ESR, and a CT scan of the abdomen.
The ESR returns back 88 and the CT scan is significant only for a “generous” spleen and aortic chain lymph nodes that are read as being top normal to slightly enlarged.
HIV test returns back positive. PPD is negative.
You again discuss with the patient his social history and discover that he is gay and that his room mate is a 44 year old male known to be HIV positive.
See question #6.
The western blot returns positive and CD4 is 320 and a viral load is 376,459 copies / ml. RPR is negative, hepatitis A, B and C are negative and toxoplasma IgG is negative. The genotype has no mutations. The patient is started on Stribild. He has resolution of his fever and night sweats. A repeat viral load at 30 days is 512 copies / ml and his viral load is below detectable limits at 4 months after starting therapy. He gained 5 pounds over the 4-month period.
Six months after starting HAART he again presents to you with complaints of nightly fevers to 104F and drenching night sweats. He complains of rapid weight loss of 15 pounds over 3 weeks, and early satiety. On physical examination you note the following changes from his original exam:
Vitals: T 39.4C P 118 R 18 BP 110 / 64 Wt.: 61 Kg.
Abdomen: palpable spleen 2 finger breadths below the left costal margin
130 / 105 /
42 / 130
3.4 \ 10.4 / 88
4.5 / 22 / 1.2\ / 32.0 \
Liver enzymes: within normal limits. LDH 428
UA: within normal limits
Blood cultures x 3 sets are drawnCXR: no infiltrates
Due to his enlarged spleen and the enlarged lymph nodes read on the previous scan, you order a repeat abdominal CT scan. The CT scan is now significant for diffusely enlarged retroperitoneal lymph nodes. Repeat PPD is negative; serologies for Histoplasma and Blastomyces are negative.
A CT guided lymph node biopsy is attempted but returns back only necrotic tissue.
The patient undergoes an exploratory laparotomy for culture and pathologic evaluation. The patient is moved to the surgical intensive care unit. He remains on a ventilator and a subclavian central line catheter is inserted. The next morning the patient spikes to 40C. You are asked to evaluate the patient for a post-operative fever.
See questions #7-8.
History, physical exam and laboratory evaluation remain unrevealing. The report of the pathologic specimen returns consistent with High Grade Hodgkins Lymphoma. The patient is started on chemotherapy with the following regimen:
The patient has rapid resolution of his fever and is discharged from the hospital. Fourteen days after his chemotherapy he again spikes a fever to 40C. He is noted by his mother to be confused, diaphoretic, and to have been bleeding from his gums.
WBC = 0.1, Hgb = 9 gms, Plt = 44. Glucose = 110, BUN = 23, Creat = 1.1, Na = 138, Cl = 103, CO 2 = 26, K = 4.5, AST = 35, PT = 11 sec, Bili = 0.5.
Chest radiograph is normal. Blood cultures have been sent.
See questions #9-13.
The patient received empiric piperacillin and tobramycin, the blood cultures grow Enterobacter cloacae, MIC are as follows: piperacillin >128, tobramycin >8, ceftazidime 2, imipenem 2, gentamicin 4, piperacillin >128, amikacin 4.
See question #14.
The antimicrobials are changed to improve the coverage; a Hickman catheter is placed for IV access as peripheral venous access has become difficult. Repeat blood cultures are sterile. Four days later the patient is still neutropenic and febrile, all cultures are negative and examination is unchanged.
See question #15
The patient has been started on voriconazole 200 mg BID,
On daily exam the following day, the Hickman catheter site is noted to be red with a small amount of serous drainage. Culture from the site has abundant growth of coagulase negative staphylococcus. The Patient has a platelet count of 44,000 making removal of the tunneled line more difficult.
See question #16.