Chest Infections: Student/Resident Case Report Poster - Chest Infections II |

Blast! It's Not Blastomycosis: Skin and Lytic Bone Lesions in a HIV Patient With Sarcoidosis FREE TO VIEW

Christopher Jackson, MD; Robert Bradsher, MD
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University of Tennessee Health Sciences Center, Memphis, TN

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):193A. doi:10.1016/j.chest.2016.08.202
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SESSION TITLE: Student/Resident Case Report Poster - Chest Infections II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Sarcoidosis in HIV patients is rare1. When it occurs, sarcoidosis presents as cutaneous and/or pulmonary disease. The greatest risk for co-infection occurs with starting HAART and increasing CD4 count. We report a case of sarcoidosis in a patient with low CD4 count, skin lesions, and pronounced osseous disease resembling blastomycosis.

CASE PRESENTATION: A 46 year old female with HIV diagnosed in 2000 was admitted to a neighboring hospital for intractable left thigh pain, skin lesions, and significant weight loss. Physical examination found limited left thigh movement and multiple papulosquamous eruptions overlying the right glabella. Laboratory studies were significant for CD4 count of 116 mm3, CD8 count of 173 mm3, undetectable viral load, and CD4/CD8 ratio of 0.7. CT imaging showed lytic destruction involving the left ischium, femoral head, lumbar vertebrae of L4-L5 and marked mediastinal adenopathy. Biopsy of the lumbar vertebral lesions showed histocytic inflammation. The patient was discharged with outpatient follow-up. She presented to our hospital with persistent left thigh pain. Given her lytic lesions and immunosuppression, she was admitted for further evaluation and treatment. Blastomycosis was the presumptive diagnosis due to clinical presentation and region of residence. She was empirically started on amphotericin B. Comprehensive testing for infectious etiologies, including Blastomyces, were negative. Biopsy of the left ischium and right glabella showed non-caseating granulomas with special stains negative for acid-fast bacilli, malignancy, spirochetes, fungi, or viral inclusions. She was diagnosed with sarcoidosis based on histopathologic findings and prescribed oral corticosteroids. Amphotericin B was discontinued. Within several weeks, her symptoms abated.

DISCUSSION: This case is distinct because sarcoidosis is uncommon in HIV patients with CD4 counts less than 200 since these cells help form granulomas1. Given our patient had a preserved CD8 count, we suspect her sarcoidosis was mediated by CD8 cells. Furthermore, the onset of sarcoidosis after initiation of HAART was seen after 16 years rather than within the typical three years. Finally, patients with HIV and sarcoidosis normally have prominent disease burden in the skin and lungs instead of the axial skeleton1.

CONCLUSIONS: Sarcoidosis is an important diagnostic consideration for HIV patients with dermatologic and osseous complaints. Availability bias should not cloud decision making when reaching a final diagnosis. Blastomycosis should be confirmed with histologic or laboratory findings. Although rare, patients can develop significant granulomatous disease despite low CD4 counts or prolonged adherence to HAART.

Reference #1: Morris, David G et al. Sarcoidosis Following HIV Infection. CHEST 2003; 124:929-935

DISCLOSURE: The following authors have nothing to disclose: Christopher Jackson, Robert Bradsher

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