[Adult-hlh-mas] Possible HLH Case Parkland [securemail]

Christian Wysocki Christian.Wysocki at UTSouthwestern.edu
Mon Aug 6 09:05:34 CDT 2018


Hi Dheepa,



If this is histo driving this inflammatory syndrome, it should improve relatively quickly with treatment of the histo.



My concern is that although his fever curve is improving a bit over the past couple of days, he still sounds very unstable.



Hard to know what his baseline CD4 count really is, as he's actively critically ill, but if it's really this low, he could have more than just Histo.



There are enlarged lymph nodes which look accessible in the axilliae.  If not turning around with amphotericin and the other broad spectrum antimicrobials, I think a LN biopsy (excisional) is warranted to rule out lymphoma/lymphoproliferative d/o.



He's on stress dose hydrocortisone, which could be increased to  dexamethasone 10mg bid until he stabilizes, although I would suggest getting the LN excised before cranking up his steroids, if can be done within the next 24 hrs.



That's my opinion.  Others?



-Chris

________________________________
From: Dheepa Sekar
Sent: Sunday, August 5, 2018 3:07 PM
To: adult-hlh-mas at lists.utsouthwestern.edu
Cc: Rosechelle Ruggiero; David Grinsfelder
Subject: [Adult-hlh-mas] Possible HLH Case Parkland [securemail]


Parkland Patient

Alpha, U (no name given on admission and patient somewhat disoriented. Family now here and involved in care)

MRN: 5027945


36 yo Honduran man presented with 1 month of fatigue and night sweats. No prior known medical history, found to have HIV and disseminated histo on this admission. Course has rapidly progressed, now intubated with ARDS and in septic shock on escalating pressor requirement.  Currently on amphotericin for histo as well as RIPE (pending AFB smears) and Bactrim IV for possible PCP. Also with +RPR and treating for secondary syphilis (macules on palms).


Workup thus far:

ferritin >42,000

thrombocytopenia (20, no other signs of hemolysis), anemia

TG 121


Other workup:

HIV +, CD4 13. histo ag positive. fungal comp fix pending. fungal culture pending.

MTB CPR neg. AFB 2/3 neg




Dheepa Sekar

PGY3 Internal Medicine

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