Case Study 7.1 – HIV and Related Complications

 

A 51-year-old Akashi Chizoba initially presented to the emergency room with a complaint of malaise and fever of several months’ duration. He denies illicit drug use, prescription opioid use or marijuana use was obtained. Physical examination was remarkable for pallor and generalized nontender lymphadenopathy.

A needle aspiration biopsy of one of his enlarged nodes revealed a mixed cell population, consistent with reactive hyperplasia. Subsequent laboratory evaluation revealed the patient to be seropositive for HIV by both ELISA and Western blot. A CD4+ cell count was 350/μL. The patient was discharged with an appointment to return to the AIDS clinic, but he was subsequently lost to follow-up.

He returned to the emergency room 16 months later, complaining of recurrent fever, persistent dry cough, and dyspnea. The chest x-ray at the time is shown in Image 1. A transbronchial biopsy specimen is shown in Image 2. He was begun on sulfa-trimethoprim with a resolution of his infiltrates and symptomatic improvement. He was discharged for follow-up in the hospital AIDS clinic.

The patient failed to keep his subsequent clinic appointments and presented three months later with recurrent dyspnea, fever, voluminous watery diarrhea, and weight loss. Chest x-ray revealed changes similar to those noted on his previous admission, which again responded to therapy with sulfa-trimethoprim. Diarrhea persisted, and a smear of a stool specimen revealed numerous acid-fast bacilli. His CD4+ cell counts at that time were 190/μL. He was again discharged, to be followed as an outpatient, and told to continue his medications.

Over the next several months, the patient’s course was characterized by memory loss, persistent diarrhea, loss of appetite, and continuing weight lossdespite antimicrobial therapy. He became progressively confused and withdrawn and required almost constant care from his partner Manuel, and friends. He was found unresponsive one morning and was brought to the emergency room. Examination revealed a markedly cachectic man responsive only to deep pain. Radiographic imaging and characteristic pathologic changes are seen in Images 3 through 5. Funduscopic examination revealed irregular areas of retinal hemorrhage and pale exudate bilaterally (Image 6). Breathing was shallow and labored. While in the emergency room, the patient expired. Attempted cardiopulmonary resuscitation was unsuccessful.

Gross findings at autopsy included cachexia (wasting); bilaterally firm, heavy, poorly aerated lungs; markedly enlarged spleen; and large, soft, pale retroperitoneal and mesenteric lymph nodes. Additional significant findings at autopsy were noted in the small bowel (Images 7 and 8); similar changes were seen in the spleen. The colon was also markedly abnormal (Images 9 and 10). Sections of the lungs revealed occasional residual accumulations of frothy, eosinophilic, intra-alveolar exudate and numerous inclusion-bearing cells similar to those present in the colon. Cytomegalovirus retinitis was seen.

The following images may help guide your discussion:

• Chest, Pneumocystis pneumonia – Radiograph Links to an external site.
• Lung, Pneumocystis pneumonia – Low power Links to an external site.
• Brain, cerebral atrophy – CT scan Links to an external site.
• Brain, HIV encephalopathy, Luxol fast blue (LFB) stain – Very low power Links to an external site.
• Brain, HIV encephalopathy – High power Links to an external site.
• Retina, cytomegalovirus (CMV) infection – Funduscopic image Links to an external site.
• Small bowel, Mycobacterium avium-intracellulare infection – Gross, mucosal surface Links to an external site.
• Small bowel, Mycobacterium avium-intracellulare infection – High power Links to an external site.
• Colon, cytomegalovirus (CMV) infection – Gross, mucosal surface Links to an external site.
• Colon, cytomegalovirus (CMV) infection – Low powerLinks to an external site.
• Brain, progressive multifocal leukoencephalopathy (PML) – Gross and high power Links to an external site.
• Brain, Toxoplasma encephalitis – Medium powerLinks to an external site.Brain,Links to an external site.
• CNS lymphoma – Medium power Links to an external site.
• Kaposi sarcoma – Clinical presentation and medium power Links to an external site.

For your INITIAL POST, students with the LAST name beginning with the letter:

• A – C: Will answer Questions 1 & 2
• D – F: Will answer Questions 3 & 4
• G – J: Will answer Questions 5 & 6
• K – O: Will answer Questions 7 & 8
• P – T: Will answer Questions 9 & 10
• U – Z: Will answer Questions 11 & 12

Initial posts and responses must be based on various resources such as textbooks, articles, and journals. Medscape, Up-to-Date, and ePocrates as supplemental resources are acceptable.

1. What do the lungs look like grossly in a patient with Pneumocystis pneumonia?
2. What other types of specimens are typically collected to detect Pneumocystis?
3. Is this patient’s course typical for an HIV-infected patient?
4. What is the significance of the falling CD4+ cell counts in this patient?
5. How is the clinical pathology laboratory evaluation used to help diagnose HIV infection?
6. How is the response to therapy assessed in AIDS patients?
7. What percent of patients with AIDS have clinical evidence of neurologic dysfunction?
8. What is the cause of the patient’s progressive confusion during the terminal phase of his illness?
9. Can you think of another disease in immunosuppressed patients that may result in demyelination?
10. How does this differ pathologically from HIV-1 aseptic meningitis, which occurs 1 to 2 weeks after seroconversion?
11. What are the more common organs involved by CMV infection in the immunocompromised host?
12. What are the common pathogens producing diarrhea in patients with AIDS? How do CMV infections differ in immunocompetent versus immunosuppressed patients?

Last name begins with “R”