Moffitt Report Pearls 1/13: Septic emboli, postinfectious GN and CD4 nadirs

Pulmonary septic emboli: Seeing these should make you search for R-sided source, either thrombophlebitis (even in peripheral veins) or R-sided endocarditis. Rarely, pulmonary septic emboli can be seen in overwhelming bacteremia without an actual source of clot!

 

Postinfectious glomerulonephritis (this patient did not have GN, but it came up due to renal failure): immune complex-mediated glomerulonephritis with multiple possible etiologies

  • Acute infective endocarditis (most commonly Staph)
  • Subacute infective endocarditis (most commonly Strep viridans)
  • Shunt nephritis: VP, vascular shunts that get infected

 

CD 4 Nadir: why is this important to know? Some situations in which it is useful

  • Can prognosticate the degree of immune reconstitution that can be expected when starting ARVs (patient’s with lower nadir’s don’t bounce back as much)
  • Can provide information regarding risk of IRIS (if reconstituting from a lower CD4, higher risk of IRIS)
  • Some evidence that patients that had a CD4 nadir <150 at some point have a higher risk of disease progression (AIDS-defining illness or death), even among patients with CD4 counts that had reconstituted >200. See this paper from the Annals in 1999
  • On a scientific level, there is some thought that there is a worsening of adaptive immunity (the population of T cells that are reconstituted are not quite as good/diverse as the original population for T cells) – thanks to Jen Babik for this pearl

 

Evernote link: http://www.evernote.com/l/APgJ9CvC-bxKtJQJxgIWA9Q_3gXvZXuw7n4/

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