Table of Contents
Washington University Experience | NEOPLASMS (HEMATOLYMPHOID) | Lymphoma, immune-compromised | 13A0 Case 13 History
Case 13 History ---- The patient was a 33 year old man with HIV diagnosed by blood analysis in 1986. Since that time he had had recurrent thrush, contracted pneumocystis carinii pneumonia (12/92), and also experienced immune thrombocytopenic purpura at that time. He developed cutaneous Kaposi's sarcoma in 1/93. In 8/93 he developed disseminated Mycobacterium avium intracellulare infection with a positive blood culture in 8/93. The patient's CD4 count at that time was 4. AZT had been begun in 1/93 but DDC and DDI had not been used. The patient developed seizures in late August and a brain biopsy in 9/93 showed CNS lymphoma. Therapy was begun with systemic and intrathecal Methotrexate. The most recent doses of Methotrexate had been given around 9/93. The patient began experiencing a fever and sore throat four days later. He was admitted for the complaints of fever and sore throat. On admission, his white count was 700 per microliter with 35% neutrophils, 62% lymphocytes, 1% monocytes, 2% eosinophils, and no basophils. The platelet count was also reduced at 104K/per microliter. The red blood cell count was reduced and hemoglobin was 7.9 gm/dl with a hematocrit of 23.5. Medications for MAI were continued. Broad spectrum antibiotics were added. The AZT was discontinued in order to reduce bone marrow suppression. By the fourth hospital day, the fever was improved but the patient had occasional episodes of nausea and vomiting thought to be secondary to the medications. The patient experienced acute onset of respiratory distress without chest pain, cough, or palpitations. The respiratory rate was 28, pulse 120, blood pressure 110/60, and temperature 37.8. Broad spectrum antibiotics were re-instituted with Vancomycin, Ceftazidime, and Gentamicin. The patient clearly expressed his desire not to be intubated or to have CPR in case of cardiac arrest. Antibiotics and comfort care were maintained and he died in 9/93.
