Sara Robinson, MD, MS, Alexander Dew, DO, MS and Matthew G. Tuck, MD, MEd
July 28, 2017
A 49-year-old man with a history of HIV infection and methamphetamine use presented with a 1-week history of right eye vision loss and a 2-month history of a non-pruritic scaly rash involving his trunk, palms, and soles. Of note, 20 days prior to presentation he self-restarted a combination anti-retroviral therapy (ART) pill containing emtricitabine, rilpivirine and tenofovir disoproxil fumarate after non-adherence of approximately one year. Besides recent use of methamphetamine, he denied any other illicit drug use and denied any alcohol or tobacco use. He had no recent travel or illnesses. He had one male sexual partner in the previous year, with whom he did not use barrier protection, but was not currently sexually active.
Physical examination revealed an afebrile, thin appearing man with a minimally reactive pupil on the right. An urgent dilated ophthalmic exam revealed leukocytes in the anterior chamber and vitreous humor of both eyes and depigmentation of the fundi, especially on the right, consistent with bilateral panuveitis. Vitreocentesis was not performed. The skin exam showed multiple macular lesions on the trunk and macules and hyperkeratosis of the palms and soles bilaterally (See Images 1-3). The exam was otherwise within normal limits. Labs revealed a CD4 count of 581 and an HIV viral load of 3,698.
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References:
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2. Karavellas MP, Plummer DJ, Macdonald JC, Torriani FJ, Shufelt CL, Azen SP, et al. Incidence of immune recovery vitritis in cytomegalovirus retinitis patients following institution of successful highly active antiretroviral therapy. J Infect Dis. 1999 Mar;179(3):697-700.
3. Workowski KA. Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines. Clin Infect Dis. 2015 Dec 15;61 Suppl 8:S759-62.
Author Information:
Sara Robinson, MD, MS, Walter Reed National Military Medical Center, Bethesda, MD. Junior Resident in Internal Medicine.
Alexander Dew, DO, MS, Walter Reed National Military Medical Center, Bethesda, MD. Senior Resident in Internal Medicine.
Matthew G. Tuck, MD, MEd, Assistant Professor of Medicine the Uniformed Services University of Health Sciences, Veterans Affairs Medical Center, Washington, DC.