Hemoptysis Mentioned Hemoptysis Mentioned in the Review of in the Review of Systems…Systems…

Gretchen Shaughnessy, MDGretchen Shaughnessy, MD

Clinical FellowClinical Fellow

Dept of Infectious DiseasesDept of Infectious Diseases

CC: Cough, weight lossCC: Cough, weight loss

45-year-old woman referred for new 45-year-old woman referred for new diagnosis of HIV. She states she started diagnosis of HIV. She states she started feeling sick about a year ago and noticed feeling sick about a year ago and noticed weight loss and night sweats. She has weight loss and night sweats. She has lost about 30 lbs over the past year and lost about 30 lbs over the past year and in August 2007 developed a cough in August 2007 developed a cough productive of yellow sputum with fevers productive of yellow sputum with fevers and chills. She got levofloxacin from a and chills. She got levofloxacin from a local family physician which improved local family physician which improved her symptoms but she continued to have her symptoms but she continued to have a mild cough.a mild cough.

HPI (cont)HPI (cont)

When she went to the doctor in August When she went to the doctor in August it was the first time she had sought it was the first time she had sought medical are in the past 10 years. medical are in the past 10 years.

Cough worsened and she was Cough worsened and she was diagnosed with pneumonia again in diagnosed with pneumonia again in December 2007. Improved with December 2007. Improved with levofloxacin again, but at her follow up levofloxacin again, but at her follow up visit she was found to have thrush. visit she was found to have thrush.

An HIV test was done that was positive An HIV test was done that was positive and she was referred to UNC ID Clinic.and she was referred to UNC ID Clinic.

ROSROS

Positive for cough and night sweats. Positive for cough and night sweats. The patient states that her cough is The patient states that her cough is currently productive of white sputum currently productive of white sputum and for the past few weeks it has been and for the past few weeks it has been streaked with blood. She states that streaked with blood. She states that each time she has gotten antibiotics she each time she has gotten antibiotics she improved but she has never completely improved but she has never completely gotten rid of her cough. Review of gotten rid of her cough. Review of systems is otherwise negative.systems is otherwise negative.

PMHPMH

G2P2G2P2 She has never been hospitalized She has never been hospitalized

and does not have any chronic and does not have any chronic medical problems other than the medical problems other than the HIV. HIV.

Allergies/MedicationsAllergies/Medications

Allergies – NKDAAllergies – NKDA Fluconazole 100mg po dailyFluconazole 100mg po daily Recently completed 7 day course Recently completed 7 day course

of Levofloxacin 500mg po dailyof Levofloxacin 500mg po daily

Social HistorySocial History

Works at a mallWorks at a mall Lives in Durham, no recent travel.Lives in Durham, no recent travel. She has 2 children ages 21. 25, and 3 She has 2 children ages 21. 25, and 3

grandchildren neither her children nor grandchildren neither her children nor grandchildren live in the house.grandchildren live in the house.

She previously smoked 1 pack a day since She previously smoked 1 pack a day since she was a teenager but quit one month ago.she was a teenager but quit one month ago.

Occasional alcoholOccasional alcohol The patient denies any contact with The patient denies any contact with

tuberculosis.tuberculosis. She has 1 dog who lives outside.She has 1 dog who lives outside.

Social History (cont)Social History (cont)

She has never been homeless and She has never been homeless and never been in prison. never been in prison.

The father of her 21-year-old The father of her 21-year-old daughter died of AIDS in the early daughter died of AIDS in the early 90s. After she heard about his 90s. After she heard about his death, she considered getting an death, she considered getting an HIV test but did not because of HIV test but did not because of fear. fear.

History (cont)History (cont)

Sexual History - Sexually active since the Sexual History - Sexually active since the age of 16. Approximately 10 lifetime age of 16. Approximately 10 lifetime sexual partners, only her current sexual partners, only her current husband for the last 10 years. He is husband for the last 10 years. He is aware of her diagnosis and is awaiting aware of her diagnosis and is awaiting HIV test results. She has no history of HIV test results. She has no history of trading sex for drugs or sex for money, trading sex for drugs or sex for money, no history of other STIs.no history of other STIs.

Family History – Father died age 59 from Family History – Father died age 59 from MI. Mother died young in accident.MI. Mother died young in accident.

Physical ExamPhysical Exam

T 37, BP 136/92 T 37, BP 136/92 P 115P 115 R 18 O2 sat 99% on room air R 18 O2 sat 99% on room air INAD, marked anxiety, INAD, marked anxiety, temporal wastingtemporal wasting EOMI, PERRLA. Nonicteric sclerae.EOMI, PERRLA. Nonicteric sclerae. Thrush PresentThrush Present, upper palate dentures. , upper palate dentures. <1cm area of <1cm area of

increased pigmentation on L tongueincreased pigmentation on L tongue Shoddy cervical LAD, all <1cm in diameter. No Shoddy cervical LAD, all <1cm in diameter. No

supraclavicular, axillary or inguinal lymph nodes. supraclavicular, axillary or inguinal lymph nodes. RRR, no m/r/gRRR, no m/r/g CTAB, No wheezes, rhonchi, or rales on my initial exam.CTAB, No wheezes, rhonchi, or rales on my initial exam. Soft, nontender. No hepatosplenomegaly, no massesSoft, nontender. No hepatosplenomegaly, no masses No clubbing, cyanosis or edema. No clubbing, cyanosis or edema. No rash or skin lesions. No rash or skin lesions. No neurologic abnormalities.No neurologic abnormalities.

LabsLabs

CD4 62, 8%CD4 62, 8% VL 507,000VL 507,000 CBC – 3.7>9.6/29.0<497CBC – 3.7>9.6/29.0<497 Diff – 2.6-0.7-0.2-0.1-0.0Diff – 2.6-0.7-0.2-0.1-0.0 PCP DFA negPCP DFA neg U/A, UCx, negU/A, UCx, neg

RadiologyRadiology

Radiology (cont)Radiology (cont)

Further Diagnostic Further Diagnostic TestsTests Sputum 3+ AFB on smearSputum 3+ AFB on smear TB-PCR negative x 2TB-PCR negative x 2 OSSA on bacterial sputum cultureOSSA on bacterial sputum culture

Sequencing of growth from AFB culture Sequencing of growth from AFB culture revealed revealed Actinomyces sp Actinomyces sp confirmed with confirmed with repeat sequencing. Evaluation for repeat sequencing. Evaluation for background MTB was negative.background MTB was negative.

Actinomyces sp.Actinomyces sp.

gram-positive filamentous gram-positive filamentous bacteriabacteria

Order of Actinomycetales, Order of Actinomycetales, family Actinomycetaceae, family Actinomycetaceae, genus genus Actinomyces.Actinomyces.

Grow slowly in anaerobic-Grow slowly in anaerobic-to-microaerophilic to-microaerophilic conditions, colonies with a conditions, colonies with a molar tooth appearance. molar tooth appearance. The most commonly The most commonly isolated species is isolated species is Actinomyces israeliActinomyces israeli

Sulfa granulesSulfa granules Not usually acid fast, but Not usually acid fast, but

one case report from 1980 one case report from 1980 when using Putt stainwhen using Putt stain

eMedicine 2008

http://www.bact.wisc.edu/themicrobialworld/dental.html

Cervicofacial Cervicofacial actinomycosis (ie, lumpy actinomycosis (ie, lumpy jaw)jaw) History of dental manipulation History of dental manipulation

or trauma to the mouth, poor or trauma to the mouth, poor oral hygiene, dental caries, or oral hygiene, dental caries, or periodontal diseaseperiodontal disease

Painless or occasionally painful Painless or occasionally painful soft-tissue swelling involving soft-tissue swelling involving the submandibular or the submandibular or perimandibular region; over perimandibular region; over time, multiple sinuses drain time, multiple sinuses drain pus containing sulfur granules; pus containing sulfur granules; tendency to remit and recurtendency to remit and recur

Reddish or bluish discoloration Reddish or bluish discoloration of the skin overlying the lesionof the skin overlying the lesion

Chewing difficulties (ie, with Chewing difficulties (ie, with involvement of mastication involvement of mastication muscles)muscles)

eMedicine 2008

NLM 2008

Thoracic Thoracic ActinomycosisActinomycosis Thoracic actinomycosisThoracic actinomycosis

– History of aspiration (Risk factors History of aspiration (Risk factors include seizure disorder, include seizure disorder, alcoholisms, and poor dental alcoholisms, and poor dental hygiene.)hygiene.)

– Dry or productive cough, Dry or productive cough, occasionally blood-streaked sputum, occasionally blood-streaked sputum, shortness of breath, chest painshortness of breath, chest pain

– Fever, weight loss, fatigue, anorexiaFever, weight loss, fatigue, anorexia

Abdominal Abdominal actinomycosisactinomycosis History of abdominal surgery, perforated History of abdominal surgery, perforated

viscus, mesenteric vascular insufficiency, or viscus, mesenteric vascular insufficiency, or ingestion of foreign bodies (eg, fish or ingestion of foreign bodies (eg, fish or chicken bones)chicken bones)

Nonspecific symptomsNonspecific symptoms– Low-grade feverLow-grade fever– Weight lossWeight loss– FatigueFatigue– Change in bowel habitsChange in bowel habits– Vague abdominal discomfortVague abdominal discomfort– NauseaNausea– VomitingVomiting– Sensation of a massSensation of a mass

eMedicine 2008

Pelvic actinomycosisPelvic actinomycosis

History of IUCDHistory of IUCD Lower Lower

abdominal abdominal discomfort, discomfort, abnormal abnormal vaginal vaginal bleeding or bleeding or dischargedischarge

HIV and ActinomycesHIV and Actinomyces

Cervical-facial Cervical-facial ActinomycosisActinomycosis in in AIDS patients reported in 1986AIDS patients reported in 1986

Endobronchial Endobronchial actinomycosisactinomycosis in in an HIV patient first reported in an HIV patient first reported in Chest in 1993Chest in 1993

A rare condition in AIDS patients. A rare condition in AIDS patients. – Possibly because of empiric Possibly because of empiric

antibiotic use?antibiotic use?

ReferencesReferences

Lowe RN, Azimi PH, McQuitty J. Acid-fast Lowe RN, Azimi PH, McQuitty J. Acid-fast actinomyces in a child with pulmonary actinomyces in a child with pulmonary actinomycosis. J Clin Microbiol. 1980 actinomycosis. J Clin Microbiol. 1980 Jul;12(1):124-6. Jul;12(1):124-6.

Takiguchi Y, Terano T, Hirai A. Lung abscess Takiguchi Y, Terano T, Hirai A. Lung abscess caused by Actinomyces odontolyticus. Intern caused by Actinomyces odontolyticus. Intern Med. 2003 Aug;42(8):723-5. Med. 2003 Aug;42(8):723-5.

Chaudhry SI, Greenspan JS. Actinomycosis in Chaudhry SI, Greenspan JS. Actinomycosis in HIV infection: a review of a rare complication. HIV infection: a review of a rare complication. Int J STD AIDS. 2000 Jun;11(6):349-55.Int J STD AIDS. 2000 Jun;11(6):349-55.

Ossorio MA, Fields CL, Byrd RP Jr, Roy TM. Ossorio MA, Fields CL, Byrd RP Jr, Roy TM. Thoracic actinomycosis and human Thoracic actinomycosis and human immunodeficiency virus infection. South Med J. immunodeficiency virus infection. South Med J. 1997 Nov;90(11):1136-8.1997 Nov;90(11):1136-8.