recommended at this time to switch to long-acting injectable medications for those with HIV and HBV.
More research needs to be done to create a long- acting injectable that has activity against HBV.
WEST NILE VIRUS ENCEPHALITIS: AN ATYPICAL CASE PRESENTATION Sepehr Sadeghi DO, Gurtaj Mahil BS, Oluwafemi Ajibola MD, Amita Krishnan MD; Department of Medicine, LSU Health New Orleans, New Orleans, LA.
Introduction: West Nile Virus (WNV) meningoencephalitis is typically associated with cerebrospinal fluid (CSF) studies consistent with lymphocytic predominance. Case: A 60-year-old male with hypertension, type 2 diabetes, stroke with left-sided hemiparesis, and epilepsy presented after being found unconscious in his backyard. He could not provide history due to a altered mental status, but his brother reported that the patient lived independently. Initially, he was only oriented to person, had a fixed rightward gaze, left hemineglect, increased muscle tone, and generalized tremors. He was hypertensive to 241/102 and febrile at 102.6o F. He was admitted to the intensive care unit for intubation and mechanical ventilation following a rapid deterioration in mental status. A computed tomography scan of his head without contrast ruled out any acute intracranial abnormalities. EEG results showed diffuse background slowing, consistent with widespread cerebral dysfunction and encephalopathy. A lumbar puncture was performed which revealed 528 white blood cells (WBC) with 82% neutrophils and 5% lymphocytes, no red blood cells (RBCs), protein of 165, and glucose of 83. Cerebral
spinal fluid (CSF) meningoencephalitis infectious studies were pan-negative, which prompted a second lumbar puncture for further evaluation. This subsequent CSF sample showed no RBCs, 84 WBCs with 87% lymphocytes, 5% neutrophils, protein 183, and glucose 46. Extensive autoimmune and paraneoplastic workup was negative. Notably, the patient experienced an unexplained renal impairment between the two CSF samples, with creatinine levels rising from 1.1 to 3.4 within two days, followed by a subsequent correction over the following two days. Serologic testing eventually confirmed the presence of an acute WNV infection given the presence of WNV IgM antibodies. The patient was subsequently transferred for neurocritical care at another facility. Discussion: This is a peculiar case of WNV encephalitis characterized by a biphasic pattern of leukocyte composition in the CSF, noted with a transition from neutrophilic to lymphocytic predominance. These findings underscore the importance of considering WNV encephalitis, even when the initial CSF analysis reveals a neutrophilic predominance, a finding typically considered to emanate from a bacterial infection.
WHAT LIES BENEATH THE SURFACE: A CASE OF AQUAGENIC URTICARIA WITH IGG3 SUBCLASS DEFICIENCY Nadjel Opamen MD, Erin Pratt MD; Department of Medicine, LSU Health, Lafayette, LA.
Introduction: Aquagenic urticaria is a rare condition with less than 100 cases documented in medical literature. This can significantly impair a patient’s quality of life. To our knowledge, there has never
ipratropium with minimal improvement. Further work-up revealed substantially low IgG with very low IgG3 subclass and 8 out of 23 positive pre- pneumococcal serotype-specific IgG antibodies. Prevnar was administered and resulted in a post- pneumococcal titer of 16 out of 23. Omalizumab was started with drastic improvement of symptoms. Repeat work-up showed persistently low IgG thus the decision was made to start monthly IVIG infusions. At this point, the patient was diagnosed with hypogammaglobulinemia with IgG3 subclass deficiency, aquagenic urticaria and vasomotor rhinitis. Since starting IVIG infusions, the patient can now tolerate rain exposure and showers 12
been a reported case of aquagenic urticaria in a patient with IgG3 subclass deficiency.
Case: A 75-year-old man with recurrent otitis media, sinusitis, and pneumonia presented with perennial pruritic urticaria and rhinitis particularly with rain exposure and during showers. He reported that he had been diagnosed with an allergy to water several years ago. The patient was initially treated symptomatically with oral antihistamines and
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