CASE 1• 55 yo man…Baker• HIV+ since 1996

• Refused bloodwork over the years as was ‘Feeling fine’

• Oral hairy leukoplakia noted on oral biopsy in 2001

CASE 1Fall 2013

• Dry cough/soboe…no fevers

• Seen by respirology…bronchoscopy negative for pathogens

CASE 1Fall 2013

Was felt to have extrinsic allergic alveolitis….type of ”Bakers lung”

Treated with a few months of prednisone with effect

CASE 1Winter 2014…still on Prednisone

• Intractable nausea and vomitting

• Admitted and diagnosed with Cryptococcal meningitis

• Multiple cutaneous KS lesions

CASE 1Winter 2014

• Steroids stopped and IV amphotericin instituted with effect…eventually switched to oral Fluconazole

CASE 1Winter 2014

• At time of Cryptococcal diagnosis…lungs had significant disseminated nodular infiltrates that were felt to represent Cryptococcal disease as part of a disseminated Cryptococcal syndrome

• No bronchoscpy done

CASE 1FEB-MAR 2014

• Discharged from hospital and ready to consider HIV meds but wants to see bloods first

• CD4 110/6% HIV viral load 98,422• Genotype clear

CASE 1FEB-MAR 2014

• Clinically still coughing without fever or SOBOE

• No headache or fever

• Multiple cutaneous KS lesions

CASE 1MAR 2014

• Still refused to start ARVS but clearly more receptive

• Wanted to see CD4 off steroids

• CD4 90/5% HIV Viral load 389,878

CASE 1APR 2014

• Initiated TDF/FTC/Raltegravir now 4 months from initiation of Cryptococcal therapy…refused PCP prophylaxis but continued on Cryptococcal maintenance therapy with Fluconazole

CASE 1APR 2014

• Cough worsened a few weeks post initiation of ARVS but no fever or flu like symptoms…otherwise improving clinically

CASE 1MAY 2014

• CT chest reveals worsening coarse nodular infiltrates in chest

• New KS lesions now slowing and older lesions beginning to darken

CASE 1MAY 2014…1 month post initiaton of ARVS

• CD4 110/7% HIV viral load 184

• Worsening respiratory symptoms with increasing soboe…unresponsive to antibacterials

• Bronchosocpy/BAL/Transbronchial biopsy performed

CASE 1MAY 2014

• No KS seen in bronchi…BAL negative for pathogens/biopsy revealed chronic inflammation

• Admitted to hospital and high dose steroids initiated

CASE 1MAY 2014

• Worsening symptoms c/w ARDS/IRIS

• Transferred to ICU and treated for bacteria/PCP/fungi

• Succumbed to respiratory illness

CASE 1JUNE 2014

TAKE HOME MESSAGE

THIS COULD HAVE ALL BEEN AVERTED WITH EARLY INITIATION OF ARVS

TRY NOT TO USE STEROIDS IN HIV