Hemoptysis Mentioned in the Review of Systems… Gretchen Shaughnessy, MD Clinical Fellow Dept of Infectious Diseases

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

HPI (cont) When she went to the doctor in August it was the first time she had sought medical are in the past 10 years. When she went to the doctor in August it was the first time she had sought medical are in the past 10 years. Cough worsened and she was diagnosed with pneumonia again in December Improved with levofloxacin again, but at her follow up visit she was found to have thrush. Cough worsened and she was diagnosed with pneumonia again in December Improved with levofloxacin again, but at her follow up visit she was found to have thrush. An HIV test was done that was positive and she was referred to UNC ID Clinic. An HIV test was done that was positive and she was referred to UNC ID Clinic.

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

PMH G2P2 G2P2 She has never been hospitalized and does not have any chronic medical problems other than the HIV. She has never been hospitalized and does not have any chronic medical problems other than the HIV.

Allergies/Medications Allergies – NKDA Allergies – NKDA Fluconazole 100mg po daily Fluconazole 100mg po daily Recently completed 7 day course of Levofloxacin 500mg po daily Recently completed 7 day course of Levofloxacin 500mg po daily

Social History Works at a mall Works at a mall Lives in Durham, no recent travel. Lives in Durham, no recent travel. She has 2 children ages , and 3 grandchildren neither her children nor grandchildren live in the house. She has 2 children ages , and 3 grandchildren neither her children nor grandchildren live in the house. She previously smoked 1 pack a day since she was a teenager but quit one month ago. She previously smoked 1 pack a day since she was a teenager but quit one month ago. Occasional alcohol Occasional alcohol The patient denies any contact with tuberculosis. The patient denies any contact with tuberculosis. She has 1 dog who lives outside. She has 1 dog who lives outside.

Social History (cont) She has never been homeless and never been in prison. She has never been homeless and never been in prison. The father of her 21-year-old daughter died of AIDS in the early 90s. After she heard about his death, she considered getting an HIV test but did not because of fear. The father of her 21-year-old daughter died of AIDS in the early 90s. After she heard about his death, she considered getting an HIV test but did not because of fear.

History (cont) Sexual History - Sexually active since the age of 16. Approximately 10 lifetime sexual partners, only her current husband for the last 10 years. He is aware of her diagnosis and is awaiting HIV test results. She has no history of trading sex for drugs or sex for money, no history of other STIs. Sexual History - Sexually active since the age of 16. Approximately 10 lifetime sexual partners, only her current husband for the last 10 years. He is aware of her diagnosis and is awaiting HIV test results. She has no history of trading sex for drugs or sex for money, no history of other STIs. Family History – Father died age 59 from MI. Mother died young in accident. Family History – Father died age 59 from MI. Mother died young in accident.

Physical Exam T 37, BP 136/92 P 115 R 18 O2 sat 99% on room air T 37, BP 136/92 P 115 R 18 O2 sat 99% on room air INAD, marked anxiety, temporal wasting INAD, marked anxiety, temporal wasting EOMI, PERRLA. Nonicteric sclerae. EOMI, PERRLA. Nonicteric sclerae. Thrush Present, upper palate dentures. <1cm area of increased pigmentation on L tongue Thrush Present, upper palate dentures. <1cm area of increased pigmentation on L tongue Shoddy cervical LAD, all <1cm in diameter. No supraclavicular, axillary or inguinal lymph nodes. Shoddy cervical LAD, all <1cm in diameter. No supraclavicular, axillary or inguinal lymph nodes. RRR, no m/r/g RRR, 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 masses Soft, 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.

Labs CD4 62, 8% CD4 62, 8% VL 507,000 VL 507,000 CBC – 3.7>9.6/ /29.0<497 Diff – Diff – PCP DFA neg PCP DFA neg U/A, UCx, neg U/A, UCx, neg

Radiology

Radiology (cont)

Further Diagnostic Tests Sputum 3+ AFB on smear Sputum 3+ AFB on smear TB-PCR negative x 2 TB-PCR negative x 2 OSSA on bacterial sputum culture OSSA on bacterial sputum culture Sequencing of growth from AFB culture revealed Actinomyces sp confirmed with repeat sequencing. Evaluation for background MTB was negative. Sequencing of growth from AFB culture revealed Actinomyces sp confirmed with repeat sequencing. Evaluation for background MTB was negative.

Actinomyces sp. gram-positive filamentous bacteria gram-positive filamentous bacteria Order of Actinomycetales, family Actinomycetaceae, genus Actinomyces. Order of Actinomycetales, family Actinomycetaceae, genus Actinomyces. Grow slowly in anaerobic-to- microaerophilic conditions, colonies with a molar tooth appearance. The most commonly isolated species is Actinomyces israeli Grow slowly in anaerobic-to- microaerophilic conditions, colonies with a molar tooth appearance. The most commonly isolated species is Actinomyces israeli Sulfa granules Sulfa granules Not usually acid fast, but one case report from 1980 when using Putt stain Not usually acid fast, but one case report from 1980 when using Putt stain eMedicine

Cervicofacial actinomycosis (ie, lumpy jaw) History of dental manipulation or trauma to the mouth, poor oral hygiene, dental caries, or periodontal disease History of dental manipulation or trauma to the mouth, poor oral hygiene, dental caries, or periodontal disease Painless or occasionally painful soft-tissue swelling involving the submandibular or perimandibular region; over time, multiple sinuses drain pus containing sulfur granules; tendency to remit and recur Painless or occasionally painful soft-tissue swelling involving the submandibular or perimandibular region; over time, multiple sinuses drain pus containing sulfur granules; tendency to remit and recur Reddish or bluish discoloration of the skin overlying the lesion Reddish or bluish discoloration of the skin overlying the lesion Chewing difficulties (ie, with involvement of mastication muscles) Chewing difficulties (ie, with involvement of mastication muscles) eMedicine 2008 NLM 2008

Thoracic Actinomycosis Thoracic actinomycosis Thoracic actinomycosis –History of aspiration (Risk factors include seizure disorder, alcoholisms, and poor dental hygiene.) –Dry or productive cough, occasionally blood-streaked sputum, shortness of breath, chest pain –Fever, weight loss, fatigue, anorexia

Abdominal actinomycosis History of abdominal surgery, perforated viscus, mesenteric vascular insufficiency, or ingestion of foreign bodies (eg, fish or chicken bones) History of abdominal surgery, perforated viscus, mesenteric vascular insufficiency, or ingestion of foreign bodies (eg, fish or chicken bones) Nonspecific symptoms Nonspecific symptoms –Low-grade fever –Weight loss –Fatigue –Change in bowel habits –Vague abdominal discomfort –Nausea –Vomiting –Sensation of a mass eMedicine 2008

Pelvic actinomycosis History of IUCD History of IUCD Lower abdominal discomfort, abnormal vaginal bleeding or discharge Lower abdominal discomfort, abnormal vaginal bleeding or discharge

HIV and Actinomyces Cervical-facial Actinomycosis in AIDS patients reported in 1986 Cervical-facial Actinomycosis in AIDS patients reported in 1986 Endobronchial actinomycosis in an HIV patient first reported in Chest in 1993 Endobronchial actinomycosis in an HIV patient first reported in Chest in 1993 A rare condition in AIDS patients. A rare condition in AIDS patients. –Possibly because of empiric antibiotic use?

References Lowe RN, Azimi PH, McQuitty J. Acid-fast actinomyces in a child with pulmonary actinomycosis. J Clin Microbiol Jul;12(1): Lowe RN, Azimi PH, McQuitty J. Acid-fast actinomyces in a child with pulmonary actinomycosis. J Clin Microbiol Jul;12(1): Takiguchi Y, Terano T, Hirai A. Lung abscess caused by Actinomyces odontolyticus. Intern Med Aug;42(8): Takiguchi Y, Terano T, Hirai A. Lung abscess caused by Actinomyces odontolyticus. Intern Med Aug;42(8): Chaudhry SI, Greenspan JS. Actinomycosis in HIV infection: a review of a rare complication. Int J STD AIDS Jun;11(6): Chaudhry SI, Greenspan JS. Actinomycosis in HIV infection: a review of a rare complication. Int J STD AIDS Jun;11(6): Ossorio MA, Fields CL, Byrd RP Jr, Roy TM. Thoracic actinomycosis and human immunodeficiency virus infection. South Med J Nov;90(11): Ossorio MA, Fields CL, Byrd RP Jr, Roy TM. Thoracic actinomycosis and human immunodeficiency virus infection. South Med J Nov;90(11):