Case history
Case history
A 32-year-old male taxi driver was found to be HIV positive during a recent hospitalisation 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. A baseline HIV viral load, full blood counts, and liver function tests, and genotype testing were ordered prior to initiation of antiretroviral therapy (ART). In the outpatient clinic, 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 diarrhoea. 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 non-significant, but he nursed his mother with TB approximately 6 years ago. His current drug history includes anti-tuberculous therapy. He has recently completed 1 week of topical mycostatin for oral candidiasis. On examination he is thin, with evidence of oral thrush and mild seborrhoeic dermatitis. He has mild bronchial breathing in his right upper chest, with mild tracheal deviation to the right. His neurological, cardiovascular, and abdominal examinations are normal. A CD4 count performed while the patient was still in the hospital was 186 cells/microlitre. He was started on ART. The patient discloses that he is married and has three children aged 6 years, 4 years, and 13 months. They are all well. Implications for testing the family for HIV are discussed with the patient.
Other presentations
The acute retroviral syndrome occurs in approximately half of patients following HIV acquisition. It is a clinical syndrome that ranges from mild, non-specific influenza-like symptoms to a florid illness that may even require hospitalisation. In the latter, acute HIV may present with aseptic meningitis or meningoencephalitis, maculopapular rash, myalgia, arthralgia, fever, hepatosplenomegaly, diarrhoeal illness (gastroenteritis or colitis), thrush or other infections such as Pneumocystis jirovecii pneumonia, and other neurological findings such as peripheral neuropathy, Guillain-Barre syndrome, or facial palsies.
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