Case history

Case history #1

A 32-year-old male taxi driver was found to be HIV-infected during a recent hospitalization for a pneumonic illness. Compatible chest x-ray findings and confirmatory sputum culture were positive for Mycobacterium tuberculosis, resulting in a diagnosis of pulmonary tuberculosis (TB). In consideration of this diagnosis, the patient had agreed to HIV testing in the hospital. HIV serology was positive by rapid HIV testing and this was confirmed on a second blood specimen. The patient was informed of the diagnosis and referred for outpatient care. In the outpatient clinic, a history obtained from the patient confirmed some months of deteriorating health. He had lost approximately 10 kg in weight and had experienced fevers, night sweats, loss of appetite, and intermittent bouts of diarrhea. In addition, 4 weeks prior to admission he had developed a productive cough and pleuritic chest pain. He had also noted a scaly skin condition at the hairline. His medical history is nonsignificant, but he nursed his mother with TB approximately 6 years ago. His current medication includes antituberculous therapy and pyridoxine. He has recently completed 1 week of topical mycostatin for oral candidiasis. On examination he is thin, with evidence of oral thrush and mild seborrheic dermatitis. He has mild bronchial breathing in his right upper chest, with mild tracheal deviation to the right. His neurologic, cardiovascular, and abdominal examinations are normal. A CD4 count performed while the patient was still in the hospital was 186 cells/microliter. He was clinically staged, based on history and findings, as World Health Organization (WHO) stage 3. A baseline viral load, complete blood counts, and liver function tests are ordered prior to initiation of antiretroviral therapy. The patient discloses that he is married and has 3 children ages 6 years, 4 years, and 13 months. They are all well. Implications for testing the family for HIV are discussed with the patient. 

Case history #2

A 26-year-old woman is 24 weeks pregnant and is offered an HIV rapid test as part of her prenatal care. Her test is positive and confirmed on a second rapid test. She is referred for general HIV care. At the HIV clinic she explains that she has been very well, with only pregnancy-related nausea and mild fatigue. This is her first pregnancy. On examination, she looks well, with mild generalized lymphadenopathy only. She has been married for 2 years and had only one sexual partner in the last 4 years. An HIV test taken at age 20 years was negative. A CD4 count is performed and she is staged as WHO stage 1. She receives counseling regarding risks to her unborn child and information about prevention of mother-to-child transmission. She has not yet disclosed her status to her partner and needs assistance with this, as well as further information about positive living and initiation of antiretroviral therapy. 

Other presentations

The acute retroviral syndrome occurs in approximately half of patients following their infection with HIV. It is a symptom complex that ranges from mild, nonspecific influenza-like symptoms to a florid illness that may even require hospitalization. In the latter it may present with aseptic meningitis or meningoencephalitis, maculopapular rash, myalgia, arthralgia, fever, hepatosplenomegaly, diarrheal illness (gastroenteritis or colitis), and other neurologic findings such as peripheral neuropathy, Guillain-Barre syndrome, or facial palsies. Laboratory findings include lymphopenia, followed by lymphocytosis with atypical lymphocytes. In some cases, CD4 cell depletion may be severe, resulting in thrush or other infections such as Pneumocystis jirovecii pneumonia. During this time, serology may be negative or indeterminate, and diagnosis is most reliable by testing for HIV RNA viral load in plasma, although p24 antigen may also be positive at this time if the test is available.

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