HALLUCINATIONS IN AN IMMUNOCOMPROMISED PATIENT Erica Mascarenhas; Department of Medicine, Tulane Health Sciences Center, New Orleans, LA.
Introduction: Varicella zoster virus (VZV) encephalitis often presents with delirium following the vesicular rash and is more common in immunocompromised patients.
varicella zoster virus DNA. His hallucinations quickly resolved with acyclovir with a 14-day course.
Discussion: Since the patient had similar mental status changes with previous biliary obstruction while not taking his ursodiol or lactulose, the initial treatment plan was to treat hepatic encephalopathy with possible biliary infection. While encephalitis was on the differential diagnosis, his hemodynamic stability, lack of disseminated skin findings and hallucination predominance did not seem like typical VZV encephalitis. Immunocompromised patients can have other life-threatening visceral organ involvement such as pneumonia or hepatitis with VZV infection. The patient’s abnormal liver function tests were thought to be due to biliary strictures but likely were related to his VZV infection. Treatment for visceral organ involvement is intravenous acyclovir for 10-14 days. Immunocompromised patients with localized rash should be treated as if they have disseminated disease with intravenous acyclovir and transition to valacyclovir to complete 10-14 days of therapy. Overall, VZV encephalitis should be treated promptly for immunocompromised patients with new rash and delirium given a high likelihood for poor outcomes if left untreated.
Case: A 72-year old male with hepatocellular carcinoma requiring liver transplant and biliary anastomotic strictures with stents presented with three days of hallucinations, nighttime delirium, and dizziness. He also endorsed back pain and rash which was consistent with shingles and treated with oral valacyclovir. He stopped taking his ursodiol and lactulose but was taking mycophenolate and cyclosporine. He had previous mental status changes which were related to biliary obstruction requiring ERCP and stents. He was started on lactulose and antibiotics for mixed hepatic and cholestatic injury given newly elevated liver function tests. His imaging and ERCP showed a patent stent without ductal dilation. He had his stent replaced out of precaution given previous presentations but his hallucinations persisted. His head imaging was negative, a lumbar puncture was done, and intravenous acyclovir was initiated. His cerebrospinal fluid had a protein of 50 mg/dL, glucose of 52 mg/dL, leukocytes of 24 with a lymphocytic predominance and positive
DRUG ERUPTION MASQUERADING AS MASTOCYTOSIS David Van, Michelle Korah-Sedgwick; Department of Medicine, LSU Health Sciences Center, New Orleans, LA.
Introduction: Mastocytosis, a hematopoietic disorder of mast cell progenitor resulting in clonal expansion and abnormal activation of mast cells, causes patients to experience allergic dermatologic and gastrointestinal symptoms. Tryptase is typically elevated in these patients. Drug eruption rashes occasionally occur with the common anti-hypertensive medications hydrochlorothiazide and Lisinopril through various mechanisms that do not involve tryptase. Case: A 60-year-old woman with uncontrolled HIV on ART and hypertension presented with a rash that started abruptly and was localized to her upper arms. She experienced associated pruritus on the first eruption. Over the subsequent 7 months, the rash slowly spread across to cover her entire body, including her face and scalp. Warm temperature
exacerbated the rash. The rash was not responsive to phototherapy, topical steroids, oral steroid tapers, or antihistamines. During the year prior to the rash, she experienced progressive wheezing and shortness of breath, 40 pounds of weight loss, in addition to diarrhea and hypotensive episodes. Tryptase was 30.4 mg/ml, which is at the upper limit of normal. Initial evaluation was concerning for a mast cell syndrome, but a forearm punch biopsy showed no elevation of mast cells on the CD117 stain. The bone marrow analysis had no immunophenotypic evidence of B or T-cell lymphoproliferation and no discrete population of mast cells (CD117 positive). The biopsy findings were more consistent with a drug-eruption rash, and her anti-hypertensive medications hydrochlorothiazide and lisinopril were discontinued. Her symptoms of pruritus and rash improved significantly over the proceeding 32
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