Case history
Case history #1
A 28-year-old woman with known HIV infection presents with headache, fever, malaise, and confusion for the last 2 weeks. The patient's last CD4 count was 10 cells/microlitre and her HIV RNA viral load was 250,000 copies/mL. She stopped taking her antiretroviral medicines a year ago. On examination, she is lethargic and oriented only to person.
Case history #2
A 35-year-old man with HIV presents with increasing shortness of breath, fever, non-productive cough, and chest discomfort for the last 10 days. His last CD4 count was 94 cells/microlitre and his HIV RNA viral load was 175,000 copies/mL. His temperature is 39°C (102°F), and pulse 130 beats/minute. On examination, oral thrush and diffuse dry rales in both lungs are noted.
Other presentations
The presentation of tuberculosis (TB) in people living with HIV (PLWH) depends on the degree of immunosuppression. Extrapulmonary disease is more common in HIV regardless of CD4 count and can affect any organ. In patients with a CD4 count above 200 cells/microlitre, TB usually presents with pulmonary disease and upper lobe infiltrates, with or without cavitation, resembling TB among HIV-uninfected people. In severely immunocompromised PLWH, TB can present with lower or middle lobe, interstitial, or miliary infiltrates, and marked mediastinal adenopathy; cavitation is less common. Chest x-ray may be normal in those with advanced immunosuppression, but acid-fast bacilli sputum smear, culture, and polymerase chain reaction are usually positive. Early initiation of antiretroviral treatment in severely immunosuppressed patients may unmask unrecognised sub-clinical TB by reconstitution of the immune system.[1][2][3]
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