Some HAART intolerance issues Eventually settles on Atripla and then Complera with durable viral load suppression and CD4 consistently around 450700 History of disc disease HTN hyperlipidemia A fib genital HSV ID: 1045027
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1. More Syphilis
2. Case53 yo man HIV+ since 1990. MSM. Not on HAART until ~2008.Some HAART intolerance issues. Eventually settles on Atripla and then Complera with durable viral load suppression and CD4 consistently around 450-700.History of disc disease, HTN, hyperlipidemia, A fib, genital HSV
3. 1/15/16 presents with rash on arms and legs, non-pruritic, fever, HA, dysphagiaRoutine labs RPR 1:32, previously NRReturns two weeks later. Rash still evident.Receives a dose of benzathine penicillin 2.4mU IM onceAcutely complains of chest pain. EKG NSR no ischemic changes. Sent to ED to r/o NSTEMI
4. In ED they note more abdominal pain complaints. Mild epigastric pain to palpationVSSStarted on zosynAbdominal CT RUQ LNs, rectal wall thickening, lung nodules, hepatic noduleLFTs elevatedReadied for LN biopsy-scheduled as out-pt
5. Symptoms mostly resolve quickly and he is dischargedDateASTALTAlk PhosWBCHgb1/2719621870313.789.91/2815520468613.151191796561/2980139612711406583/217101355.411.0
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10. In March seen again in clinicMuch improved. Chest pain, abdominal pain resolved.LN biopsy cancelledRepeat CT scan shows resolution of intrabdominal and pelvic LNs, resolution of hepatic hypodensities
11. Another case- a bit ‘unbaked’74 yo female with HTN. No DM.Presents to ID Clinic for follow up after hospital stay for left foot ulcer in area of hardware placed to stabilize a charcot joint.Now 8 weeks of various antibiotics including FQs and metronidazole.Foot is much improved with no evidence of local or systemic inflammationThis is one of several hospitalizations for the same thing. Previously also treated with long courses of beta lactams.
12. Why the Charcot Joint? No diabetes. Told she had ‘a slipped disc’On exam she has sensory deficits in both LEs. Otherwise no gross neuro findings.Review of her chart shows she was seen by Neurology three years earlier. They determined she had polyneuropathy involving the hands and feet. No evidence on MRI causing ‘radiculopathy’.Found to have diminshed sensation to pin prick, proprioception, vibration. More in the LEs, less in the UEs.They gave her Vitamin B12 but doubted this was the cause.
13. Treponemal IgG reactiveRPR 1:1B12 normalHIV negativeHgbA1c nlLupus and other autoimmune markers all normalACE normalNo other Neuro visits. No NCS/EMGs.No specific syphilis therapy.
14. Is this a case of tabetic arthropathy?How should it be managed?