MOFFITT AM REPORT PEARLS 6/20/16: Fournier Gangrene and IRIS!

Thanks to Hala for presenting the case of a middle-aged man with HIV on newly started HAART who presented with acute diffuse skin lesions concerning for infection, IRIS, or other! Great discussion about a relatively undifferentiated case!

Fournier gangrene:

  • Necrotizing soft tissue infection of the perineum (consider as necrotizing fasciitis!)
  • Can occur in women (labial/perineal involvement) but “Fournier” is technically dx in men
  • All age groups but usually older men
  • Breach in integrity of GI or GU mucosa
  • Presentation is severe pain, can spread rapidly to abdominal wall, gluteals, scrotum/penis
  • A type I necrotizing soft tissue infection (type 1 = polymicrobial, type II = group A strep)
  • Caused by facultative organisms (E. coli, Klebsiella, Enterococcus) + anaerobes (Bacterioides, Fusobacterium, Clostridium, anaerobic strep)
  • Tx: Early aggressive drainage/debridement (call urology stat!)
  • Abx: Vancomycin + carbapenem + clindamycin (antitoxin effect vs staph/strep)
  • Mortality 22-40%!

PIC

 

IRIS: Generally diagnosis of exclusion!

No specific diagnostic criteria, but the following should be present:

  1. AIDS with low pretreatment CD4 count (<100), except TB IRIS which can occur at any CD4 count!
  2. Virologic and immunologic response to ART
  3. Rule out drug resistant infection, bacterial superinfection, drug reactions, noncompliance
  4. Clinical manifestations of inflammation
  5. Temporal association between HAART initiation and onset of illness features- One week to a few months (median 48 days)

Ddx: Progression of OI, new OI, drug reaction.

Most common pathogens associated with IRIS:

  • TB
  • MAC
  • CMV
  • PCP
  • HSV
  • HBV
  • HHV8

Treatment:

  • Continue ARVs in most cases unless life threatening IRIS or concern for permanent sequelae
  • Steroids and NSAIDs have case report evidence to support use
  • Prevention: Certain OIs should be treated for approx. 2 weeks before ARVs initiated if possible (Cryptococcus, CMV retinitis) to prevent IRIS

 

ARV skin reactions:

Most common are morbilliform rash sparing the face and urticaria

  • NNRTIs

Jaundice

  • Atazanavir causes benign jaundice (not an indication to stop drug)

SJS/TEN

  • NNRTIs (nevirapine, efavirenz) and PIs (amprenavir, darunavir, indinavir)

DHS/DRESS

  • Abacavir (contraindicated if HLA-B*5701 allele), nevirapine, enfuvirtide

 

Evernote: https://www.evernote.com/shard/s272/sh/5747ec9f-1cb8-47ad-bd54-9351c78de12c/e0874378cfdd8770bd58597345c7d504

 

EvEveEEFVA

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