Patient Case

Presentation
Sabreen Bux
General Medicine Rotation
October 2022
Patient Overview + Presentation

KW is a 28-year-old female who presented to the emergency

department on October 6, 2022 with:
o Left-sided periorbital edema and erythema
o Ocular discharge
o Rash

Upon presentation, patient complained of:

o Eye pain + pressure behind left eye
o Headache
o Chills

*Patient has no pertinent home medications

Past Medical History + Significant Labs

o HIV infection (untreated) o Plt: 128 k/cumm

since 2017 o MDW: 26.08 units
o Abs CD4: 202/mm³
o Hepatitis C infection o AST: 95 units/L
(untreated) o ALT: 102 units/L
o SCr: 0.53 mg/dL
o IV Drug/Substance use o HR: 59 bpm
o RR: 12 br/min
o Tobacco use o BP: 117/76 mm/Hg
 Patient Problem List
Zoster Opthalmicus and associated encephalitis ; Primary problem
upon admission

MSSA Bacteremia secondary to IV Drug Use/Substance Abuse

Untreated HIV Infection

Untreated Hepatitis C
 Herpes Zoster Opthalmicus (Shingles)
o Results from reactivation of latent varicella-zoster virus (VZV)

o Usually presents as a painful unilateral dermatomal rash that progress through several stages ,
followed quickly by papules that appear proximally to distally clear vesicles within 1-2 days, with
new vesicles forming over 3-5 days

o Herpes zoster opthalmicus involves the first division of trigeminal nerve (ophthalmic nerve)

o May present with ophthalmic symptoms such as eye pain and no rash

o May involve entire eye and lead to complications such as stromal or neurotrophic keratitis, uveitis,
scleritis, episcleritis, or retinal necrosis, causing permanent scarring or vision loss

o Patients may experience nonspecific symptoms such as headache, photophobia, and malaise but
significant associated systemic symptoms such as fever are uncommon

o Most common complication is postherpetic neuralgia (PHN); more serious complication is VZV
dissemination involving the CNS causing encephalitis
Gershon, A., Breuer, J., Cohen, J. et al. Different Phases of Varicella zoster virus infection. Nat Rev Dis Primers 1, 15016 (2015). https://doi.org/10.1038/nrdp.2015.16
Editorial AUK. Anatomy of the trigeminal nerve. Anaesthesia UK : Anatomy of the trigeminal nerve. https://www.frca.co.uk/article.aspx?articleid=100533.
Published September 14, 2005. Accessed October 18, 2022.
 Risk Factors + Diagnosis of HZO

o HIV Infection o In immunocompetent individuals, diagnosis is

o Female
o Immunosuppression due o HZ may present with atypical skin lesions (eg,
to pharmacotherapy or
autoimmune disorders
o Increasing age
o Spinal surgery
based solely on the clinical presentation-
unilateral, usually painful vesicular eruption with a
well-defined dermatomal distribution
hemorrhagic), especially in immunocompromised
individuals. When the diagnosis is uncertain,
laboratory confirmation is indicated. Diagnostic
techniques include polymerase chain reaction
(PCR) testing, direct fluorescent antibody (DFA)
testing, and viral culture
 Herpes Zoster Opthalmicus Treatment
o Systemic antiviral agents initiated within Adjunctive therapy:
72 hours of skin lesions help relieve
symptoms, speed resolution, and
prevent or mitigate PHN.
o Valacyclovir: 1,000 mg PO TID
o Famciclovir: 500 mg PO TID
o Acyclovir: 800 mg q4h (5 doses daily)
o Duration: 7 days or 10-14 days
o APAP or NSAIDs for mild-to-
moderate pain
o Opioid analgesics, tramadol,
gabapentin, or pregabalin for
moderate-to-severe pain
o Steroid treatment is
controversial; oral prednisone
has been used in the past
 KW-Herpes Zoster and associated
encephalitis treatment course
Started on 10/6:

o IV Acyclovir 600 mg q8h x 21 days then transition to suppressive dosing

o Erythromycin ophthalmic ointment applied BID to skin lesions and left eye

o Artificial tears QID

o Warm compresses to periocular skin TID

o Prednisolone ophthalmic suspension

o For pain: Tylenol, Ibuprofen, Ketorolac and Gabapentin

 MSSA Bacteremia
o All patients with S. aureus bacteremia should undergo a transthoracic echocardiography TTE
or transesophageal echocardiography (TEE) to rule out infective endocarditis. TEE is preferred
in patients that use intravenous drugs.

Empiric therapy:
o Vancomycin load 20 to 35 mg/kg followed by 15 to 20 mg/kg infusion every 8 to 12 hours
o Daptomycin 8 to 10 mg/kg intravenously once daily

Treatment following susceptibility results:

o Beta-lactam agent such as nafcillin (2 g IV every four hours), oxacillin (2 g IV every four
hours), flucloxacillin (2 g IV every six hours), or cefazolin (2g IV every eight hours)
o For continuation of intravenous therapy in outpatient settings, cefazolin may be more
practical and better tolerated than anti-staphylococcal PCNs

o Once the diagnosis of MSSA bacteremia has been established and treatment has been
initiated, blood cultures should be repeated to document clearance of bacteremia.
 KW- MSSA Bacteremia Treatment
o Based on blood cultures and labs collected from an outside hospital, patient was
initiated on treatment for MSSA bacteremia

→ Procalcitonin: 0.07
→ Blood cultures: 1/4 blood cultures from OSH were growing MSSA
→TEE: Mitral valve endocarditis

o Empiric therapy: Vancomycin 1.5 g x 1 dose and 1 g x 2 doses

o MSSA treatment: Nafcillin 12 g q 24 hours at 20.83 mL/hr x 6 weeks

HIV Opportunistic Infection Prophylaxis
o Anti-retroviral therapy reduces the incidence of opportunistic infections and is
associated with improved morbidity and mortality.
o Directly correlated with CD4 count

o Pneumocystis jiroveci (PCP): CD4 counts < 200 cells/µL or <14%

→Bactrim DS 1 tablet daily
→Dapsone 100 mg daily (in patients with sulfa allergy)

o Toxoplasmosis: Positive Toxoplasma IgG (+) or CD4 < 100 cells/µL

→ Bactrim DS 1 tablet daily

o Mycobacterium avium: CD4 count <50 cells//µL

→ Azithromycin 1,200 mg once weekly or 600 mg twice weekly
 KW- HIV Infection
o Patient was started on Biktarvy for a brief period in 2020 but stopped due to
transportation barriers

o Genotyping was conducted and showed no resistance to Biktarvy, was started on it

again

o Testing for hepatitis B virus is recommended prior to the initiation of ART. Hepatitis
B surface antigen was nonreactive

o G6PD deficiency test negative

o HLA B*5701 test negative

 Other Inpatient Treatments
o DVT prophylaxis: Lovenox + SCDs

o Opioid W/D: Methadone 10 mg BID

o Nicotine W/D: Nicotine patch 21 mg and 14 mg, Nicotine Gum

o Pain: Gabapentin 600 mg TID

o Sleep aid: Trazodone 100 mg

KW- Overall Treatment/Monitoring Plan

Current Pertinent Labs: o Continue IV acyclovir for 1 more week; monitor

renal function and hydration status, possibly
decrease dose to suppressive dosing
o Na: 130-140 mmol/L
o Abs CD4: 202/mm³ o Continue Biktarvy; Re-check CD4 count in 1
o AST: 44 units/L month, HIV VL 2-8 weeks after initiation of
therapy, and SCr
o ALT: 86 units/L
o SCr: 1.51 mg/dL o Continue IV Nafcillin until 11/18, monitor SCr,
o BG: 222 mg/dL LFTs due to hepatic elimination, Na due to
sodium load of Nafcillin

o Gabapentin monitor SCr, mental alertness and

behavioral changes
 Patient Care Plan Critique
o Duration of therapy for acyclovir dosing, guidelines recommended 10-14 days for
immunocompromised patients or complications such as encephalitis

o Continuing IV acyclovir-longer duration could put patient at increased risk for infection,
dosing frequency is a concern with the oral dosage form

o Obtaining CD4 count was appropriate, important to continue to monitor outpatient;

should be re-checked in 1 month

o HIV Viral load should also be monitored 2-8 weeks after starting therapy

o Choice of Methadone for pain/opioid withdrawal, make sure to address best option for
opioid dependence given patient’s barriers to care; barrier to starting suboxone would
be finding a provider with X waiver

o Have not initiated HCV treatment, active substance use is not a contraindication
 References
1. Albrecht MA. Epidemiology, clinical manifestations, and diagnosis of herpes zoster.
UpToDate. https://www.uptodate.com/contents/search#! Published June 20, 2022. Accessed
October 17, 2022.
2. DynaMed. Herpes Zoster. EBSCO Information Services. Accessed October 18, 2022.
https://www.dynamed.com/condition/herpes-zoster
3. Gershon, A., Breuer, J., Cohen, J. et al. Different Phases of Varicella zoster virus infection. Nat
Rev Dis Primers 1, 15016 (2015). https://doi.org/10.1038/nrdp.2015.16
4. Editorial AUK. Anatomy of the trigeminal nerve. Anaesthesia UK :&nbsp;Anatomy of the
trigeminal nerve. https://www.frca.co.uk/article.aspx?articleid=100533. Published September
14, 2005. Accessed October 18, 2022.
5. Fowler VG, Holland TL. Clinical approach to Staphylococcus aureus bacteremia in adults.
UpToDate. https://www.uptodate.com/contents/search#! Published September 28, 2022.
Accessed October 18, 2022.
6. DynaMed. Prevention of Opportunistic Infections in Patients With HIV. EBSCO Information
Services. Accessed October 18, 2022. https://www.dynamed.com/management/prevention-
of-opportunistic-infections-in-patients-with-hiv