1. CASE 1 55 yo man…Baker HIV+ since 1996 Refused bloodwork over the years as was ‘Feeling fine’ Oral hairy leukoplakia noted on oral biopsy in 2001

2. CASE 1 Fall 2013 Dry cough/soboe…no fevers Seen by respirology…bronchoscopy negative for pathogens

3. CASE 1 Fall 2013 Was felt to have extrinsic allergic alveolitis….type of ”Bakers lung” Treated with a few months of prednisone with effect

4. CASE 1 Winter 2014…still on Prednisone Intractable nausea and vomitting Admitted and diagnosed with Cryptococcal meningitis Multiple cutaneous KS lesions

5. CASE 1 Winter 2014 Steroids stopped and IV amphotericin instituted with effect…eventually switched to oral Fluconazole

6. CASE 1 Winter 2014 At time of Cryptococcal diagnosis…lungs had significant disseminated nodular infiltrates that were felt to represent Cryptococcal disease as part of a disseminated Cryptococcal syndrome No bronchoscpy done

7. CASE 1 FEB-MAR 2014 Discharged from hospital and ready to consider HIV meds but wants to see bloods first CD4 110/6% HIV viral load 98,422 Genotype clear

8. CASE 1 FEB-MAR 2014 Clinically still coughing without fever or SOBOE No headache or fever Multiple cutaneous KS lesions

9. CASE 1 MAR 2014 Still refused to start ARVS but clearly more receptive Wanted to see CD4 off steroids CD4 90/5% HIV Viral load 389,878

10. CASE 1 APR 2014 Initiated TDF/FTC/Raltegravir now 4 months from initiation of Cryptococcal therapy…refused PCP prophylaxis but continued on Cryptococcal maintenance therapy with Fluconazole

11. CASE 1 APR 2014 Cough worsened a few weeks post initiation of ARVS but no fever or flu like symptoms…otherwise improving clinically

12. CASE 1 MAY 2014 CT chest reveals worsening coarse nodular infiltrates in chest New KS lesions now slowing and older lesions beginning to darken

13. CASE 1 MAY 2014…1 month post initiaton of ARVS CD4 110/7% HIV viral load 184 Worsening respiratory symptoms with increasing soboe…unresponsive to antibacterials Bronchosocpy/BAL/Transbronchial biopsy performed

14. CASE 1 MAY 2014 No KS seen in bronchi…BAL negative for pathogens/biopsy revealed chronic inflammation Admitted to hospital and high dose steroids initiated

15. CASE 1 MAY 2014 Worsening symptoms c/w ARDS/IRIS Transferred to ICU and treated for bacteria/PCP/fungi Succumbed to respiratory illness

16. CASE 1 JUNE 2014 TAKE HOME MESSAGE THIS COULD HAVE ALL BEEN AVERTED WITH EARLY INITIATION OF ARVS TRY NOT TO USE STEROIDS IN HIV