1. NYU Medical Grand Rounds Clinical Vignette Sunnie Kim, MD PGY3 Tuesday, May 29, 2012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. The patient is a 25 year-old man who presents for follow-up for chronic leukopenia and requesting HIV testing and counseling, as well as information about pre-exposure prophylaxis. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. History of multiple male sexual partners. Six months prior to presentation was evaluated after a high-risk sexual contact with condom malfunction and penile laceration. Treated with 28-day course of zidovudine, tenofovir and lamivudine for post-exposure prophylaxis. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. Also evaluated and treated for chronic facial acne vulgaris in dermatology clinic. Having failed topical antibiotics and antimicrobials, was initiated on isotretinoin. During this time, he was noted to have persistent leukopenia and was referred to medicine clinic. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. The patient also requests HIV testing, and counseling on means of prevention, including medications or vaccines. He reports several HIV-negative friends on chronic anti-retroviral therapy for HIV prevention. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Additional History Past Medical and Surgical History None Social History: Multiple concurrent male sexual partners Inconsistent condom use No known history of sexually transmitted infections Occasional MDMA/ecstasy use Occasional alcohol use with intermittent binge drinking Family History: none Allergies: NKDA Medications: Isotretinoin 20mg bid U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Physical Examination Well appearing. Vitals: T97.8F, BP 106/62, HR 61, RR 16 Numerous hyperpigmented macules and atrophic scars over the face and upper back. Otherwise normal examination U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Prior Laboratory Findings CBC: WBC 3.1 (N 59%, L 34%, Eos 6%, Baso 1%) Hg 14.1g/dl Platelets 182,000 Cr 0.9mg/dl AST 41mg/dl (11-39) ALT 45mg/dl (11-35) The remainder of the hepatic panel and basic metabolic panel was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Mildly elevated transaminases with leukopenia - chronic viral infection - iatrogenic from chronic acne treatment (antimicrobials or isotretinoin) Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. The patient received counseling on safe sex practices including consistent condom use. No HIV vaccine is currently available for clinical use. Pre-exposure prophylaxis was not initially offered to the patient due to limited evidence and interim CDC guidelines. Scheduled for follow-up visit for further counseling. Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. The patient screened negative for HIV, hepatitis B and C, gonorrhea, and chlamydia infections. Repeat CBC showed stable WBC (3.1-5.0) Transaminases normalized after completion of isotretinoin treatment. Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Otherwise healthy man engaging in high-risk sexual activities despite counseling. Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS