INTRODUCTION
CASE IN DETAIL
SL has been experiencing progressive lethargy over the past 2 months. His lethargy is so severe that he feels exhausted even on minimal exertion. Over this period he has noticed weight loss of about 10 kg despite a well-preserved appetite, and watery diarrhoea without associated abdominal pain, vomiting or nausea. Over the past 2 months he has been suffering from occasional epistaxis that spontaneously resolves. This has gradually progressed in frequency and on presentation he was experiencing epistaxis about four times a week. Each episode settles spontaneously and he loses about 20 mL blood. He denies any bleeding from other mucosal surfaces and denies frequent bruising.
He started to develop high fevers up to 39°C and drenching night sweats 1 month ago. For the past week he has been experiencing night sweats almost every night. He denies any cough, headache or urinary symptoms. He did not seek medical help until 3 days ago, when he presented to the HIV outpatients clinic for his 3-monthly follow-up. On assessment, he was referred for hospital admission for further investigation and management. Since admission he has had multiple blood tests and imaging studies, including CT scans of the head, chest and abdomen, a gallium scan, testing of urine and stool samples and a bone marrow biopsy.
SL was diagnosed with HIV infection 5 years ago when he presented with progressive dyspnoea, significant weight loss and seborrhoeic dermatitis. He was diagnosed with Pneumocystis carinii pneumonia on this presentation, and treated with intravenous and oral trimethoprim and sulfamethoxazole together with oral prednisolone. Since his recovery from the acute episode he has been maintained on trimethoprim and sulfamethoxazole 160/800 mg, one tablet daily, for secondary prophylaxis. He claims good compliance with this treatment and denies any side effects. On recovery from the P. carinii pneumonia he was commenced on antiretroviral therapy with zidovudine. He tolerated this agent well. Three years ago zalcitabine and indinavir were added to the regimen due to viral count rebound.
He experienced severe ureteric colic due to nepholithiasis after the commencement of this combination. Indinavir was ceased immediately. He was maintained on zidovudine and zalcitabine until 1 year ago when saquinavir was added to the regimen after a progressive decline in the CD4 count was noted. He did not experience any distressing side effects with these medications. Six months ago he voluntarily stopped all antiretroviral therapy because he found consuming so many tablets a tremendous inconvenience.
When his HIV infection was first diagnosed, his CD4 count was 0 and the viral load 230000 HIV RNA copies/mL. His most recent CD4 count taken 3 days ago when he presented at hospital was 100/mL and the viral load was 20 000 HIV RNA copies/mL.
He was diagnosed with cytomegalovirus retinitis one year ago when he presented with blurred vision and occasional floaters in the left eye. He was treated with intravenous ganciclovir for a period of 3 weeks and then changed to oral ganciclovir. He is currently maintained on 2 g ganciclovir three times a day. He denies any side effects associated with this therapy. He has follow-up with the ophthalmologist every 3 months and claims that he is compliant with the therapy.
He has experienced oral candidiasis twice in the past, the first time 4 years ago and then again 5 months ago. He was treated with oral fluconazole on both occasions. He is maintained on 150 mg fluconazole daily. He has not experienced any side effects with this treatment.
He denies any other opportunistic infections in the past.
He was diagnosed with diabetes mellitus 10 years ago when he presented with polyuria and polydipsia. The diabetes was considered to be a complication of the haemochromatosis, which was diagnosed subsequently. His diabetes was treated with combination insulin initially and he is now on twice-daily rapid-acting insulin, 40 units in the morning and 25 units at night before meals. He monitors his blood sugar levels twice daily and the recent readings have been between 6 and 8 mmol/L. He is compliant with the diabetic diet. He has never experienced hypoglycaemic episodes or suffered from diabetic ketoacidosis.
His general practitioner has investigated him for diabetic nephropathy with spot urine tests. The last test was done about 6 months ago and he was informed that he had no protein in his urine. He has never performed a 24-hour urine collection for testing. He denies any symptoms of chronic renal insufficiency. He sees his ophthalmologist every 3 months and has not been told of any diabetic retinopathy or cataract formation. He denies any visual symptoms currently. He has never seen a podiatrist. He has experienced paraesthesias of the distal extremities in both the upper and lower limbs, but has never had formal nerve conduction studies performed. He denies postural dizziness or impotence.
His haemochromatosis was diagnosed 10 years ago when his diabetes was investigated. He was initially treated with two 3-monthly desferrioxamine infusions followed by 6-monthly infusions for 2 years. He has not had any therapy for haemochromatosis for 8 years. His GP monitors his serum iron levels every 6 months. He denies any known hepatic involvement or any other complications of haemochromatosis.
In summary, his current medications are trimethoprim-sulfamethoxazole, ganciclovir, fluconazole and insulin.
He denies any allergies to medications.
He is an adopted child and therefore does not know whether there is any significant medical history in the family. He has never known his biological family.
He lives on the sixth floor of an apartment block with his partner. He has lived with two other partners previously and his first partner died of an AIDS-related illness. This was a traumatic experience for SL, even though he was separated from the man at the time of his demise. His second partner is also HIV-positive. He has been living with his current partner for the past 3 years and he is HIV-negative. Prior to meeting his first steady partner and after the two previous separations, he had unprotected sexual intercourse with multiple other partners on a casual basis. He has never suffered from any other sexually transmissible disease. He has been vaccinated against hepatitis B and hepatitis A in the past.
His current partner is very sympathetic and supportive. SL does not have any children.
He uses the lift to get to his apartment, and he has two steps inside his apartment that he negotiates without any difficulty.
He smokes 30 cigarettes a day and has a smoking history of 60 pack-years. He rarely, if ever, consumes alcohol. He smokes marijuana regularly at weekly intervals and rolls his own joints. He denies any other recreational drug use.
SL denies any sleep problems and has a satisfactory appetite. He has felt depressed at various times but has never sought medical help for this. He denies any current feeling of depression or suicidal ideation. He worked as a business consultant until 3 years ago when he decided to stop work due to lack of motivation. Currently he survives on sickness benefits, which he finds inadequate to support his lifestyle.
ON EXAMINATION
SL appeared cachectic. He had a depressive affect. His estimated body mass index was about 20. His pulse rate was 70 beats per minute, and it was regular in rhythm and normal in character. With the adoption of an upright posture his pulse rate rose to 90. His blood pressure was 110/70 mmHg without a postural drop and he was afebrile. His respiratory rate was 16 per minute at rest. He was alert and very cooperative. His cognitive function was intact, with a Mini-Mental State score of 30/30.
He had an intravenous cannula in his right forearm and the cannula site was not inflamed. He was not receiving any intravenous therapy at the time of examination. There was seborrhoeic dermatitis on the forehead and the nose as well as in the ventral aspect of the left forearm. No other cutaneous lesions were observed.
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