E-case #15

April 16-20

Tom Heller, M.D.

36 y/o gay, non-drug using male, HIV+ since 1987, was my patient from 1990to 1994, during which time he declined antiviral therapy.  CD4 count dropped from 610 to 480 during that four-year period.  He was lost to follow-up for the subsequent four years during which he later said he was "in denial"about his infection.  He presented in 8/98 with one-month history of fevers,dry cough, progressive dyspnea, and 10-lb. weight loss.  Temp was 100.8,RR-28, O2 sat-92%, lungs clear, chest xray- +/- diffuse increasedinterstitial lung markings.

At this point what is your differential, and what would you do?  (See case discussion)

Upon recovery he was started on Nelfinavir, D4T, and 3TC, plus TMP-SX DS qdfor PCP prophylaxis and Azithromycin 1200mg once weekly for MAC prophylaxis(CD4 count drawn at the time of presentation was 10).  CD4 count rose to 78and viral load dropped from 200,000 to 900 in the first month.  However, by late October 1998, he reported a 3-wk hx of fever, night sweats,non-productive cough, very swollen lymph nodes in the R axilla, and another10 lb loss.  Exam revealed him to be in no respiratory distress with RR-20,O2 sat of 95%, Temp-100; rales heard in both upper lobes, which were dull to percussion; large matted lymph nodes palpable in rt axilla.  Chest xray:bilateral upper lobe infiltrates, and hilum more prominent than on earlier films.

What to do next?  (See case discussion)

Chest CT showed 6.5x3x4.5cm mass of lymph nodes in rt axilla, 2 cmmediastinal nodes in aortopulmonary window, and bilateral upper lobe infiltrates with associated pleural thickening.  On the second hospital day pt developed acute swelling and erythema over lateral aspect of rt.pectoralis which pointed and drained copious amount of exudate.Simultaneously, rt. axillary nodes decreased in size dramatically.  Acid fast stain of exudates was positive, and subsequently cultured positive for mycobacterium avium intracellulare.  He was presumptively treated for TB and discharged from hospital after repeated induced sputum samples were acid fast negative.

Upon definitive diagnosis, he was switched to a five-drug regimen for MAI,which was maintained for 18 months during which time sinus tract closed, wt returned to baseline, and symptoms resolved.  Antiviral therapy was also maintained.  CD4 count rose progressively from 78 to 255 to 394, 507, and last month was 610 with an undetectable viral load.  He feels great handworks full time.

E-case #15 Discussion

Tom Heller, M.D.

8/98 presentation is so classic for PCP that some providers would treat empirically.  However, miliary TB , mycobacterium avium complex, viral pneumonia, or lymphoma could present similarly, and so I have never felt empiric treatment was wise especially given the toxicity of high disfeaturing administered for three weeks (GI intolerance, rash, marrow suppression) and the potential harm caused by delay in making correct diagnosis.  In this case, patient was referred for bronchoscopy; BAL was positive for pneumocystis.  Because baseline O2 sat was greater than 91%,steroids were deemed unnecessary, and pt was treated as outpatient with 3 wk course of TMP-SMX (20mg TMP/kg/day) w/o complications and with prompt response.

10/98 presentation-what to do?  Hospitalize in isolation!  This is TB until proven otherwise.  Other possibilities: MAC, lymphoma, Nocardia,Actinomycosis, other fungal pathogens.

Take Home Points

I present this case to make three primary points.

1. The first is that when dealing with the AIDS patient, the law of parsimony does not apply.  The law of parsimony was the invention ofa 14th century philosopher named William of Ockham (and often goes by the name of Ockham's razor), who determined that a unifying cause for multiple phenomena is most likely to be correct.  In medicine that would suggest that multiple and often disparate symptoms presenting at the same time in one patient are more often than not due to one pathologic process.  In AIDS, the opposite is true; one clinical presentation is as likely as not to be due to two or more pathologic processes.  In this case, the patient undoubtedly already had a smoldering case of mycobacterium avium intracellulare at the time that his PCP was diagnosed.

2. The second point is an obvious one, that HIV is a chronic and often grueling condition and it is not uncommon for the patient to "burnout" and drop out of sight of his or her physician to try to "demedicalize"life.  It is important for a doctor caring for AIDS patients to work withina team that includes a case manager, who can track patients down who have dropped from sight; and of course, it is crucial to identify and treat depression that frequently accompanies the disease and contributes to non-adherence and burn out.

3. The third point is that HIV has become an enormously gratifying condition to treat.  The paper by Lee, et al, cited below documents the change in survival rates from 1984 to 1997.  Between 1984 and 1992, two year survival after an AIDS defining illness rose from 20% to 40%.  From 1992 to1997, it rose from 40% to 80%.  As someone who has been caring for patients with AIDS since 1984, witnessing this development first hand has been awesome.  Keeping current with treatment choices is intellectually stimulating and eminently doable.  The paper by Carpenter, et al cited below provides updated recommendations as of 2000, though there have been some new developments since then including the cited paper by Staszewski, et al,which helps establish the appropriate use of a triple nucleoside regimen(which has the distinct advantage of being packaged in a single capsule resulting in a triple drug regimen in one pill twice daily).  The recent introduction of a new protease inhibitor, Kaletra, adds yet more complexity to treatment decisions.  I would be glad to see your HIV patients in consultation or help you in your management decisions by phone or e-mail. This is work I think we could all be doing.

E-case references

Lee,LM, et al, Survival after AIDS diagnosis in adolescents and adults during the treatment era, United States, 1984-1997, JAMA,285,1308-1315,2001.

Carpenter, et al, Antiretroviral therapy in adults:  updated recommendations of the International AIDS Society-USA Panel, JAMA, 283,381-391,2000.

Staszewski, et al, Abacavir-lamivudine-zidovudine vsindinavir-lamivudine-zidovudine in antiretroviral-naïve HIV-infected adults,JAMA 285, 1155-1163,2001.