Severe leg pain in an HIV-positive man.

AIDS: A case study is presented of a 55-year-old man with long-term HIV infection. His treatment history and current viral load are presented. The patient is reporting increasingly severe leg pain which has hampered his ability to walk and which is negatively impacting his quality of life. His case is discussed by Abigail Zuger, MD, who describes avascular bone necrosis and potential treatments for the symptoms.^ieng

An alarming x-ray in a patient who feels well.

AIDS: A 27-year-old woman, who is being successfully treated for HIV, has mostly normal results from physical examinations and feels well. Yet she had a chest X-ray that showed prominent perihilar adenopathy and a miliary pattern in all lung fields. Medical records from an open lung biopsy, photographs taken during the biopsy, and the pathology reports reveal histoplasma capsulatum infection, a rare occurrence in late-stage HIV infection, especially without concurrent symptoms including fever, wasting, cytopenias, and oral and intestinal ulcerations. It is not known whether the patient's highly active antiretroviral therapy allowed her to react to this organism as immunocompetent persons do, which is with well-formed granulomas. Her travel history was evaluated and showed that she had briefly passed through histoplasma-endemic areas of the southern United States. However, tests for histoplasma antigens returned negative, as did tests for serum histoplasma antibodies. Two immunohistochemical stainings for PCP were also both negative. The patient is being treated with Itraconazole, and may also be treated with a 3-week course of atovaquone for recurrent PCP.^ieng

Treating a survivor.

AIDS: A case study is presented of a 27-year-old male, in the late stages of AIDS, who benefitted from recent advances in HIV therapy. During recovery from his fourth episode of pneumocystis pneumonia and newly-diagnosed disseminated Mycobacterium avium (MAC) infection, he agreed to take antiretrovirals. He received treatment with indinavir, Epivir, and stavudine, and then had stavudine replaced with AZT due to adverse effects. He also received treatment for MAC. His diarrhea and fevers disappeared, his appetite returned, and he gained 50 pounds. A tinea infection on his back and face resolved, as did persistent oral candidiasis. Although HIV myelitis was suspected during treatment, it stabilized, or even improved. The patient became discouraged when his viral load rose from 2,100 to 5,700, and trying to make him understand that his initial loads were probably near a million copies did not reassure him. Referral to a clinical psychologist seemed to help, and he continues to do well on therapy.^ieng

Adherence to highly active antiretroviral therapy.

AIDS: Case studies of three HIV-infected patients are presented that emphasize their struggles and attitudes toward the demands imposed by adherence to highly active antiretroviral therapy. The physicians who are treating these patients tried to select the most effective regimens within the limits of assumed adherence. When these patients were followed, the patients whom the physicians predicted would do poorly did well, while the more presumed competent patient did poorly. The discussion reinforces the unpredictability of choosing which patient will be able to live with complex daily medication schedules.^ieng

Tuberculosis-like illness in a young man from Thailand.

AIDS: A case study is presented of a mid-20's, HIV-infected male visitor from Thailand who became increasingly ill with tuberculosis-like symptoms. The question addressed is whether the patient should be treated for miliary tuberculosis or for disseminated Mycobacterium avium complex (MAC) infection pending further evaluation. It is argued that due to the frequency with which Penicillium marneffei infection occurs in Thai AIDS patients and the similarity of the symptoms to MAC infection, such treatment is not warranted. Following isolation of P. marneffei, the patient was treated with high dose amphotericin B and responded well, defervescing within a week.^ieng

Jaw swelling in an HIV-infected man.

AIDS: A case study is presented in the diagnosis and treatment of a late-stage HIV-infected male who presented with an irregularity in his jawline, a 4-cm firm mass near his left mandibular angle. The mass was diagnosed by CT scan as a greatly enlarged cervical node with a necrotic center, including enlargement of several other nodes. Treatment ultimately involved the use of rifabutin and ethambutal. Differential diagnosis ruled out a malignancy and pathologic studies showed that the mass was typical of mycobacterial adenitis, caused by Mycobacterium avium complex (MAC). Diagnostic difficulties and follow-up history are provided.^ieng

Two worlds, two hopes.

AIDS: The International Conference on AIDS, held in Vancouver in July 1996, showed two distinct themes. One was optimism, and researchers were cheered by the advent of viral load testing, the development of other antiretroviral drugs, and new schemes to slow the progression of the disease. However, at the same time that there is so much hopeful news, AIDS is continuing to spread. In Africa, Asia, and India, more than 90 percent of the world's infections can only be treated with a fraction of the budget. Even simple antibiotics are not available, and the use of expensive medications like protease inhibitors is not even considered. The economics of this virus are becoming more difficult to resolve.^ieng

Profound neutropenia in an HIV-infected man.

AIDS: A 35-year-old man from Central America with a history of AIDS and numerous opportunistic infections presented with progressive neutropenia and thrombocytopenia despite having been stable for a period of 6 months. Cessation of antiviral medications did not stop his neutropenia, nor did use of folinic acid, G-CSF, or erythropoietin. The failure of these measures required repeated blood transfusions. Although the physical examination was relatively unremarkable, hematology and blood chemistries indicated that the patient needed urgent hospitalization due to fever and neutropenia. Neutropenia within HIV infection can be confusing, since it may be a result of the infection itself, an adverse effect of drug therapy, or from an opportunistic infection or malignancy. If the cause is not evident, it is wise to seek the etiology first rather than immediately use bone marrow stimulants, such as G-CSF. In this case, an infectious disease specialist made a diagnosis of disseminated histoplasmosis, after which the patient was treated with amphotericin B and released on itraconazole maintenance therapy.^ieng

Home HIV test goes to market.

AIDS: The Confide HIV home-testing kit produced by Direct Access Diagnostics has been given the go-ahead by the Food and Drug Administration (FDA) although the kit remains controversial. The controversy lies primarily in the use of the telephone for counseling. AIDS advocates and physicians believe telephone counseling is inadequate despite the company's assurances about the education and training of its counselors. Proponents think high-risk groups will be more likely to get tested and also point out the success rates of suicide hotlines.^ieng

She's having a baby.

AIDS: As the survival rates of HIV-positive persons increase, the issue of conceiving children is being raised. An HIV-positive mother should be concerned at every stage of pregnancy, from conception to delivery. HIV-positive children may have particularly difficult lives, including physical difficulties and the potential loss of both parents. While few studies show that the risks of pregnancy-induced immunosuppression compound HIV complications in HIV-positive women, clinical complications, if they do occur, can be stubborn to treat.^ieng

Brain abscess and pneumonia in an HIV-infected woman.

AIDS: A 34-year-old HIV-infected female was treated for pneumonia and suspected cerebral toxoplasmosis. Sulfa and macrolide antibiotics were discontinued after adverse effects were observed, and clindamycin was begun. Following the change in medication, the patient's neurologic status worsened, leading to a search for other diseases. She was tested using a stereotactic brain biopsy and Nocardia was isolated. After treatment with a third-generation cephalosporin and a tetracycline antibiotic, her neurologic symptoms waned, and both lung and brain lesions were shown to be improved in subsequent studies.^ieng

Severe sore throat in a patient with AIDS.

AIDS: A case of a 45-year-old HIV-infected male who developed a severe throat infection with serious complications is reported. Despite a low CD4 count, the patient suffered only one significant illness in ten years since his diagnosed HIV infection. Overly aggressive antibiotic therapy caused fungal and thrush infections, leading to dehydration and extreme weight loss. The patient was treated with rehydration therapy, antifungal agents, and TMP-SMX, after which other complications, including multiple infections and B-cell lymphoma, were diagnosed. He refused chemotherapy after one course of treatment and was sent home with hospice care.^ieng

A difficult case of PCP.

AIDS: A case history is presented of an HIV-infected female patient with a recurrence of Pneumocystis carinii pneumonia (PCP) and contraindications to use of most drugs for PCP, including pentamidine, trimethoprim-sulfamethoxazole (TMP-SMX), clindamycin, primaquine, and dapsone. Treatment alternatives discussed address risk-benefit analyses of using different drugs. The final treatment decision was to use escalating doses of TMP-SMX, since her previous adverse effects (fever and rash) are not an absolute contraindication to readministration of the drug. Results of this TMP-SMX were good with trivial side effects.^ieng