SocialMedicine Posted December 18, 2011 Share Posted December 18, 2011 A 40 year old male presents with a swelling in the R suprapubic/inguinal region. The swelling is hard, nonmobile, slightly tender and1X2 inches. It is likely a lymph node. He reports this for 3 weeks with no improvement. He says "is this a hernia?". and wants further ideas on how to treat it, figuring it would go away on its own. PMHx: none known, physical approx 2 years ago and "fine" MEDS: None PSHx: None What comes next? As I am writing this I am realising this might not be as interesting as I though 3 minutes ago but lets see. Link to comment Share on other sites More sharing options...
Just Steve Posted December 18, 2011 Share Posted December 18, 2011 Just a first year student, so consider the source... ROS for GU, sexual history, muscle/skeletal, respiratory, general. Wondering about fevers, weight loss, night sweats, STIs/recent contacts, change in urination habits, distal neuromuscular function, recent injury/trauma? Did the mass show up at once? Has it been larger than it's current presentation? How fast did it grow? Can you reduce the mass manually? Since you say it's firm and non mobile, I am going to assume no...Any visible changes to the skin locally? Any physical abnormalities elsewhere? Other nodes? Testes of regular shape/size/tenderness? Any noted urethral discharge? Hows the prostate feel? Spleenomegly? Ultrasound show any blood flow to the mass? Are you able to discern what sort of structure you're dealing with via ultrasound? I don't know if you can do a fine needle biopsy of a firm mass or not, but if possible...would now be the time? Link to comment Share on other sites More sharing options...
SocialMedicine Posted December 18, 2011 Author Share Posted December 18, 2011 ROS for GU, sexual history, muscle/skeletal, respiratory, general. Wondering about fevers, weight loss, night sweats, STIs/recent contacts, change in urination habits, distal neuromuscular function, recent injury/trauma? Did the mass show up at once? Has it been larger than it's current presentation? How fast did it grow? ROS NEGATIVE.No penile lesion, d/c, dysuria, frequency, hesitancy. No fever, dyspnea, pain, reports some weight gain but intentional as he lifts weights. STIs? HE has a history of anal HPV and chlamydia/gonorrhea. No recent trauma. Motor/sensory exam in the LE is intact. Says "I feel fine" Sexually active with men and is likely a sex worker. Mass is onset over few days starting 3-4 weeks ago. Can you reduce the mass manually? Since you say it's firm and non mobile, I am going to assume no...Any visible changes to the skin locally? Any physical abnormalities elsewhere? Other nodes? Testes of regular shape/size/tenderness? Any noted urethral discharge? Hows the prostate feel? Spleenomegly? No rash. Does not reduce with supine position. Non mobile, firm, slightly tender. No other LN swelling inguinal, axillary, neck, etc.. Testicle exam normal. No mass, tenderness, symmetry present. No discharge. Normal prostate exam. No organ megaly. Ultrasound show any blood flow to the mass? Are you able to discern what sort of structure you're dealing with via ultrasound? Not sure what the value of an US would be here. I did not order one. It seemed very likely a LN as opposed to inguinal hernia, abscess. I guess it could help r/o a lymph node abscess. But usually there is alot of tenderness and overlying erythema with that. I don't know if you can do a fine needle biopsy of a firm mass or not, but if possible...would now be the time? Reasons not to do a biopsy .... risk of nerve damage, infection, time, money etc. Altho low risk for this area. If you want to run it we can. I am not saying it is right or wrong. Any other tests to do before hand? Link to comment Share on other sites More sharing options...
VictoriaO Posted December 18, 2011 Share Posted December 18, 2011 Green newbie PA here, how's his GA? Does he look sick? body habitus? Any lesions/scratches on the legs? Any other skin findings anywhere else? Any other LAD present? Any recent foreign travel? Does he practice safe sex? Animal exposure? Any history of inflammatory diseases or CA? I'd like a rapid HIV, GC/CT, RPR/VRDL, CBC diff to start off the top of my head, please. By the way is this in clinic, urgent care, ER? Link to comment Share on other sites More sharing options...
SocialMedicine Posted December 18, 2011 Author Share Posted December 18, 2011 Green newbie PA here, how's his GA? Does he look sick? body habitus? Any lesions/scratches on the legs? Any other skin findings anywhere else? Any other LAD present? Any recent foreign travel? Does he practice safe sex? Animal exposure? Any history of inflammatory diseases or CA? He looks well. In no apparent distress. muscular habitus. black pigmented skin, IDs himself as African American. Does not use condoms consistently for oral or anal sex with male partners. Travel to dominican republic 2 months ago. no hx of CA, autoimmune, or inflam disease. I'd like a rapid HIV, GC/CT, RPR/VRDL, CBC diff to start off the top of my head, please. Rapid ELISA HIV type 1 is positive, RPR negative, CBC within normal range. No shift, no elevations. By the way is this in clinic, urgent care, ER? primary care/internal medicine practice with HIV/STD interests. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted December 18, 2011 Moderator Share Posted December 18, 2011 Lgv???????? Link to comment Share on other sites More sharing options...
Just Steve Posted December 18, 2011 Share Posted December 18, 2011 not knowing what LGV is, I let google help me out. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001658/ Sounds really good match on some fronts, but with the lack of lesions and skin changes I'd be interested to see some other ideas. With the ultrasound I was chasing the notion of a tumor. The theory I was rolling through my brain was if the mass has a vascular supply, then I may lean towards tumor. Please try not to laugh to loud at my thought pattern...Clinical medicine starts next term so I'm sure I'll see the error of my thoughts in a few months. With the night sweats I was angling towards some sort of TB weirdness. I was formally under the impression that TB was primarily a pulmonary disease but I have since learned that little bug has legs and can travel to all sorts of crazy places. With the patient's history, this drives straight down Infectious Disease lane. My map of that road is still being drawn up. I'll have to take a backseat and let others navigate. Link to comment Share on other sites More sharing options...
VictoriaO Posted December 18, 2011 Share Posted December 18, 2011 We had a cool case of axillary lymph node extra-pulmonary TB (Tubercular lymphadenitis) during one of my rotations, the CT was very impressive. With LGV, wouldn't it have to be a strain of C. trach? Looks like the tx would be Doxy BID if his C. trach came back +, not to mention the rest of his work-up results (concommitant syphilis?). I'd also want a Hep B test on this guy too if he's not vaccinated. My first instinct would be to fine-needle aspirate and see what grows if the GC/CT is (-), (how fast does a CD4 count come back?), plate for acid-fast bugs. possibly fungal depending on his CD4? Could even be toxoplasmic (from my reading, can potentially present as a single LAD in HIV +). If we were thinking TB after ruling out C. trach, I'd shoot for a Quant Gold (TST is often (-) with extrapulmonary so I read). I'd think he might be a bit sicker with extrapulmonary TB, plus isolated inguinal is rare, but HIV pts are more succeptable to this manifestation. Thanks Social Medicine for the excellent case! I love me some ID Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted December 19, 2011 Moderator Share Posted December 19, 2011 TB is a a good thought as is lymphoma but both of those should be slow growing. I'm interested to see what the final dx is. I think he needs some imaging and a biopsy regardless of other work up. Link to comment Share on other sites More sharing options...
SocialMedicine Posted December 19, 2011 Author Share Posted December 19, 2011 With LGV, wouldn't it have to be a strain of C. trach? Looks like the tx would be Doxy BID if his C. trach came back +, not to mention the rest of his work-up results (concommitant syphilis?). I'd also want a Hep B test on this guy too if he's not vaccinated. Certain less common serovars of C. Trach are the culprits behind LGV. Urine NAT negative for CT GC. No current infection with HBV. RPR nnegative. Did you want any other tests to determine lf LGV or Syphilis is ongoing? My first instinct would be to fine-needle aspirate and see what grows if the GC/CT is (-), (how fast does a CD4 count come back?), plate for acid-fast bugs. possibly fungal depending on his CD4? Could even be toxoplasmic (from my reading, can potentially present as a single LAD in HIV +). A Biopsy is scheduled end of week, in the interim you determine a CD4 count in the mid 500's and a viral load HIV-1 at 50,000 copies. Going over his risk factors he reports unprotected sex with a man living with HIV few months ago followed by an ER visit for "Strep throat" with a negative rapid GAS strep and flu like symptoms (muscle ache, HA, joint pain) followed by "allergic reaction" to amoxicillin of which he has used before without problem. The reaction was a systemic rash erythematous macular circular less than .5CM. My guess is all these Sx were his primary HIV infection. Frequently missed in the ER ... not blaming them though. HIV related malignancy is rare in new HIV. However, malignancy that was on my differential as this could be an anorectal cancer. A man with anal HPV for many years is certainly at high risk for anorectal cancer. On initial exam an anoscopy was performed alongside CT/GC rectal cultures. Both were negative. He reported bright red blood per rectum but could be do from sex practices or frequent hemerrhoids. If we were thinking TB after ruling out C. trach, I'd shoot for a Quant Gold (TST is often (-) with extrapulmonary so I read). I'd think he might be a bit sicker with extrapulmonary TB, plus isolated inguinal is rare, but HIV pts are more succeptable to this manifestation No TB screening done, lets just say a Quant Gold is negative which is reasonable to use given his current CD4 count. Link to comment Share on other sites More sharing options...
deborah212 Posted December 19, 2011 Share Posted December 19, 2011 Going over his risk factors he reports unprotected sex with a man living with HIV few months ago followed by an ER visit for "Strep throat" with a negative rapid GAS strep and flu like symptoms (muscle ache, HA, joint pain) followed by "allergic reaction" to amoxicillin of which he has used before without problem. The reaction was a systemic rash erythematous macular circular less than .5CM. I wonder if besides HIV, he could have also have concomitant EBV. The systemic macular rash following amoxicillin sounds like the exanthem typical of EBV. Link to comment Share on other sites More sharing options...
SocialMedicine Posted December 19, 2011 Author Share Posted December 19, 2011 It is possible his "strep" was an EBV infection. I would guess a 40 year old man in sex work had been exposed to EBV previously which would mean if he had another exposure or reactivation it would not be as bad. But it doesnt have to be this way. I tend to see alot of newly infected and recently diagnosed HIV patients (someone who just tested positive who had recent negative tests) who had a likely primary infection treated with antibiotics and then they are "allergic" to the Abx when the common rash of primary HIV happens (which it does in over 70% of symptomatic cases some reports say). This was not as exciting a case as I thought hah. EMEDPA with his many years of experience was right on. While urinary tract testing was clear of chlamydia trach his blood revealed a high titer of IGG Abs towards this bacteria. His CBC, LDH, CHEM, RPR, GC/CT, UA, PSA, GI/GU exam all WNL. Malignancy not very likely in this case, especially given an unremark personal and family history and no const Sx or complaints (I am not aware of any study showing elevated malignancy incidence in men/women living with HIV for under a year controlling for increased smoking and vital hepatitis etc of course). He started on Doxycycline and will still meet with the surgeon to see if biopsy should still be done. THe plan is to repeat the IGG Ab level in 2 weeks to see if their is an expected rise in the titer. Why did I think to post this? I have been in HIV practice for 3 years and up until this week never saw a case of LGV. This last week I saw two cases. Not sure if NYC is about to have an outbreak or if this is coincidence. Anyways , I figured if I have only had two cases most have had none. I have treated more syphilis than probably the entire state of North Dakota has this past year. hah. If this was syphilis you would expect the RPR to be positive by now. It generally takes a few weeks from exposure to be positive. LN swelling is more of a secondary Sx, it is when a chancre or primary syphilis is present that diagnostic difficulties emerge. The way to culture for syphilis is very difficult and not practical in clinical settings. As a result people are often treated presumptively in this stage with bicillin 2.4million UNIT injection. Interestingly Doxy is the second line drug but certain locations can have alot of resistance. I wonder what syphilis infection would look like ona LN biopsy? :shrug: I will try to come up with something better next time :). Link to comment Share on other sites More sharing options...
VictoriaO Posted December 19, 2011 Share Posted December 19, 2011 Thank you very much, Social Medicine. This was a great case to review HIV/STIs and their sequelae. Hopefully next month I can start to contribute cases, I'll be starting as the first PA hospitalist at a major academic center. Saw a few albino zebras there as a student... Link to comment Share on other sites More sharing options...
Just Steve Posted December 19, 2011 Share Posted December 19, 2011 Albino Zebras..nice. :-) Thanks Social Medicine, I appreciate a case that I felt I could follow a bit. Learned a few things along the way, so that's always a bonus. I have been totally blown away at the sequelae of STIs. Not having ever studied them previously, all I knew was what they teach in high school health class. So many other systems are affected. Crazy stuff. It shows there is a very practical base to doing a thorough ROS of sexual history, no matter how "awkward" or "not important" it may seem on the surface. Happy Holidays Link to comment Share on other sites More sharing options...
Moderator ventana Posted December 19, 2011 Moderator Share Posted December 19, 2011 thanks - might be "routine" for you but stopped and made me think hard and I was not right in my assessment - question from a primary care guy...... would you repeat an HIV test for someone recently negative who developes a "viral syndrome" and developes a rash to abx (I know abx don't work on virus but.... even tight wad me even treats a URI with ABX) how long does it take for seroconversion with HIV - in that initial outbreak of s/s will they be +? I have done 0,6,12 week follow up testing for needle sticks and exposure - should the same be done with ? primary HIV infection? last question - any photos of the rash of HIV and any hints on how to seperate this from the typical viral syndrome? Link to comment Share on other sites More sharing options...
mdebord Posted December 19, 2011 Share Posted December 19, 2011 Great case - I'd never even heard of LGV before! Link to comment Share on other sites More sharing options...
SocialMedicine Posted December 20, 2011 Author Share Posted December 20, 2011 The rash of primary HIV is difficult to differentiate. When I see a patient with flu like symptoms (especially if it is a bit atypical such as lasting 3-4 weeks, rash present, rectal or urethral symptoms) I will make a comment like "any HIV concerns?" "any unprotected sex or recreational drug use". If the answers are affirmative I will run HIV-1 PCR testing alongisde HIV Ab testing. If you have primary HIV than you will have HIV virus in your system period. If PCR is positive before antibodies have developed this represents a big early treatment opporunity with the possibility of greater immune preservation than treated otherwise. HIV antibodies typically form within 4-6 following exposure, over 98% of those who will live with HIV following an exposure will have antibodies by 3 months. They recommend testing 1 year out to be 100%. There is a small eclipse period where HIV is in the lymphoid tissue following exposure and not detectable by PCR In blood. This lasts no more than 2-4 weeks. In summary if someone has HIV risk and flu like symptoms run HIV pcr testing. Down sides? More expensive maybe 2-300$ in NY Used to be a greater risk of false positives, still is I suppose, but new test technology is very accurate. If a very low HIV viral load I would probably repeat to be certain before making any diagnosis. Test can take a few days. I have concerns people request the test in order to engage in risky behavior. For example a group of people agrees to get the viral load test done so they can have risky behaviors. I do not believe any empircal data supports this statement, it is anecdotal. Link to comment Share on other sites More sharing options...
MikeyBoy Posted December 24, 2011 Share Posted December 24, 2011 Interesting case. Saw 2 LGV cases one year ago in a STD clinic here on the east coast. Both recent immigrants from Africa. Link to comment Share on other sites More sharing options...
sk732 Posted December 25, 2011 Share Posted December 25, 2011 Saw one case of LGV before - he had actual bubos in his groin, was pretty ugly...and the aspirate grew C.trachomatis, not plague bacillus :-). Link to comment Share on other sites More sharing options...
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