ZSFG Pearls 8/9: CD4, +GM w/ Zosyn, Lymphomatoid Granulomatosis

Thanks to Chuka for presenting a case of a patient with an entity familiar to us all: Lymphomatoid Granulomatosis.

 

First, let’s start with a few general HIV/ID pearls from Kat Christopoulos:

  • On CD4 counts: normal values are >1000 (%>30); if CD4 is below 200=AIDS
  • CD4 Nadir is important: If HIV is untreated, pt’s count will rapidly drop to nadir
  • Repeat bacterial infections are also an AIDS/HIV defining illness
  • Efavirenz (part of Atripla when combined with Tenofovir/Emtracitabine or Truvada) is known for the neuropsychiatric side effects of nightmares, insominia, ?SI along with wooziness as it majorly acts on the 5HT-2A receptor
  • There have been reports of false-positive results of galactomannan (more than of beta-D-glucan) in patients who have been receiving Piperacillin-tazobactam (Zosyn) due to cross-reactivity with the antibiotic formulation
    • False-positive results can persist for as long as 5 days after d/c’ing Pip-tazo
    • Recent literature suggests that the current Pip-tazo formulation we’re using rarely react with the assays (see below)
  • We reviewed PCP dx and tx, also beautifully summarized on this blog post: https://ucsfmed.wordpress.com/2016/04/06/sfgh-4-5-am-report-pearls-pcppneumonia/

 

Now a note on Pulmonary Lymphomatoid Granulomatosis (PLG)…
lymphom gran

  • Overall, PLG is a form of lymphoproliferative disorder, in the category of B cell proliferations of uncertain malignant potential
  • Associated with Epstein-Barr virus (EBV) infection or meds like MTX, azaothioprine or in pt’s with underlying immunodeficiency
  • It’s uncommon pulmonary disorder characterized by multiple pulmonary nodular lesions with lymphocytic invasion of vascular walls on biopsy
  • Diagnosis hinges on histopathologic triad of polymorphic lymphoid infiltrates, transmural infiltration of arteries and veins by lymphoid cells (“angiitis”), and focal areas of necrosis within the lymphoid infiltrates
  • Mortality rates exceeded 50% with reported median survivals from the time of diagnosis ranging from 14 to 72 months
  • Treatment follows regimens for diffuse large B cell lymphoma; rituximab

 

References:

 

Evernote link: https://www.evernote.com/shard/s354/sh/56133d1a-71b5-4299-b01d-325a2a73ea71/984b32c268511e59a7232c2840504e09

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