Case 4: A 32-Year-Old with Fever, Weight Loss, and Fatigue

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Authors: David H. Spach, MD
Joel E. Gallant, MD, MPH

Case last updated: June 30, 2004

A 32-year-old man presents with a 3-week history of fever, fatigue, and abdominal pain. The patient was diagnosed with HIV 7 years prior and most recently had a CD4 count of 8 cells/mm3 and HIV RNA of 88,000 copies/ml while taking a regimen of abacavir (Ziagen) plus didanosine (Videx EC) plus lopinavir-ritonavir (Kaletra). The patient was supposed to be taking once weekly azithromycin (Zithromax) for prevention of disseminated Mycobacterium avium complex (MAC) infection, but discontinued several months prior because of gastrointestinal side effects. The physical examination shows a very thin male with a temperature of 39.2°C and palpable hepatosplenomegaly. Abnormal laboratory studies include a hematocrit of 24% and an alkaline phosphatase of 310 U/L. An abdominal CT scan shows hepatosplenomegaly and multiple large retroperitoneal and mesenteric lymph nodes. Based on the overall presentation, the patient’s medical provider concludes the most likely diagnosis is disseminated MAC infection.

Which of the following statements is TRUE regarding disseminated MAC infection in AIDS patients?

	The anemia would be unusual with MAC and would strongly suggest a diagnosis other than MAC.
	Among patients with disseminated MAC, fewer than 45% will have blood cultures that turn positive within 21 days. Thus, if MAC is suspected, the patient should proceed to bone marrow aspirate and culture to improve the diagnostic yield.
	The 2002 U.S. Public Health Service 2002 Guidelines for Preventing Opportunistic Infections state that secondary prophylaxis (to prevent recurrence of disseminated MAC) may be discontinued in patients treated with HAART who have a sustained (greater than 6 months) increase in CD4 count to greater than 100 cells/mm3 if they have completed 12 months of MAC therapy and have no ongoing symptoms or signs attributable to MAC.
	The preferred therapy for disseminated MAC consists of clarithromycin (Biaxin), rifabutin (Mycobutin), and clofazimine (Lamprene). Recent studies have shown that clofazimine decreases the MAC relapse rate more than ethambutol (Myambutol) and thus it has replaced the ethambutol in the preferred MAC treatment regimen.