Newly Diagnosed Human Immunodeficiency Virus

Newly Diagnosed Human Immunodeficiency Virus

from Southern Medical Journal

Case Report

A 38-year-old Hispanic man with no significant medical history came to the emergency room with complaints of a "10/10" retroorbital headache, photophobia, fevers, and a rash. The patient reported that he was in his usual state of good health until 2 weeks before admission, when he was placed on a 14-day course of TMP-SMZ (Bactrim DS), loratadine (Claritin), and acetaminophen for symptoms of cough, rhinorrhea, and sinus congestion. Despite treatment, symptoms continued. Myalgias, intermittent chills, and subjective fevers developed 1 week before admission. Two days before admission, a diffuse "red rash" and conjunctivitis developed. Treatment with sulfacetamide ophthalmic solution was started the evening before admission. Eye pain intensified after administration of the ophthalmic solution, and the patient had a headache that prompted the emergency room visit.

The patient denied nausea, vomiting, diarrhea, or weight loss. He denied any recent travel, unusual food, or animal exposure and reported that one coworker was ill with pneumonia. He reported being heterosexual and appropriately using a condom during his last sexual encounter 7 months earlier. He denied history of blood transfusion; use of tobacco, alcohol, or intravenous drugs; or homosexual activity. There was no history of medication allergies or previous exposure to TMP-SMZ.

On examination, the patient appeared thin, ill, and in moderate distress. Vital signs were blood pressure 95/54 mm Hg, heart rate 118/min, respiratory rate 22/min, and temperature 101.7°F. Physical examination was notable for nonicteric sclera, marked bilateral conjunctival injection, photophobia, shoddy cervical adenopathy, and lack of meningeal signs. The oropharynx was erythematous without exudate, lesions, or ulcers. Cardiac and lung examinations were normal. There was a diffuse, nonblanching, erythematous, macular eruption over the torso with no evidence of target lesions. There was 1+ pretibial, pitting edema bilaterally. Laboratory values were white blood cell count of 5.1 x 109/L (53% segmented neutrophils, 39% band forms, 7% lymphocytes, and 1% monocytes), hemoglobin 149 g/L, hematocrit 43.7%, and platelets 249 x 109/L. Liver-associated enzyme levels were elevated, with alkaline phosphatase 131 U/L (normal, 38 to 126 U/L), aspartate aminotransferase 103 U/L (normal, 14 to 36 U/L), alanine aminotransferase 111 U/L (9 to 52 U/L), and total bilirubin 8.55 mmol/L. Lumbar puncture revealed clear, colorless fluid with negative Gram's stain, white blood cell count 22 x 109/L (97% lymphocytes, 2% segmented neutrophils, 1% monocytes), protein 0.74 g/L, and glucose 2.66 mmol/L. Serum glucose was 5.66 mmol/L. Electrolytes, prothrombin time, partial thromboplastin time, and urinalysis were normal. Computed tomography of the sinuses and a chest radiograph were unremarkable.

The patient was admitted to the hospital, sulfa-containing medications were discontinued, and intravenous (IV) piperacillin sodium-tazobactam sodium (Zosyn) and IV erythromycin were started, given the clinical picture consistent with sepsis. The infectious diseases and dermatology services were both consulted, and the patient's symptoms were thought to be consistent with those of a hypersensitivity reaction to sulfa drugs. During hospital day 1, he continued to have fevers up to 103°F, with persistent rash, myalgias, and headache. On the second hospital day, a capillary leak syndrome developed, manifested by pulmonary edema, a mild coagulopathy without bleeding, and peripheral edema. Oxygen and supportive measures were used. On hospital day 3, he was afebrile without headache, and the rash was resolving. All blood, urine, and cerebrospinal fluid cultures done on admission remained negative for organisms, and antibiotics were discontinued. He was monitored without recurrence of fever, coagulopathy resolved, liver enzymes normalized, and the chest's appearance on radiographs returned to normal. He was discharged on hospital day 6 in improved health.

After discharge, Lyme electroimmunofluorescence assay, hepatitis serologies, and fungal cultures remained negative. Enzyme-linked immunosorbent assay and Western blot done during hospitalization were positive for HIV, with HIV-1 RNA of 33,313 copies/mL. Initial CD4 count was 483 (21%). The patient was informed of his HIV status. He denied any identifiable risk factors for HIV infection. Treatment was initiated with lamivudine-zidovudine (Combivir) and nelfinavir mesylate. Six months after discharge, his viral load was below the detectable level with a CD4 count of 794 (25%).

This is a part of article Newly Diagnosed Human Immunodeficiency Virus Taken from "Claritin Loratadine 10Mg" Information Blog