LECTURE COMMENTS

HIV Disease - Opportunistic Infections and Tumours in Brief Case Studies

Feb-21-2024

Case No 1

 

Medical History

A 38-year-old male did not know about his HIV+

 

  • 2 months fatigue, weight loss, back pain, feelings of heat (T not measured)
  • He reduced sports activities
  • He had dry cough one month, breath shortness as he walked up the stairs
  • Pulmonary X-ray and spirometry: negative findings, Rx. co-amoxycillin
  • Gradually increasing dyspnea (lower limb vein ultrasound)
  • Phys. exam: poor, eupnoe, practically normal lung sounds, SpO2 norm.
  • Labor.:
    • BC norm. (just Mo 14%)
    • Bioch.: LD 7.7 ukat/l
    • Anti-HIV+, CD4+ 225
    • X-ray and HRCT

 

 

 

 

 

 

 


  • Induced sputum: Pneumocystis – PCR, microscopically
  • Pneumocystis jiroveci pneumonia

 

 

 

 

 

 


Case No 2

 

51-year-old male, actor, HIV+ dg. 1989, poor adherence, 2015 CD4+ 81, VL HIV 224 000 cp/ml, 2016: a week growing dyspnea, does not mentally accept his seropositivity

  • BC: leu 6,9, ery 3,2, tr 290
  • Bioch.: CRP 115, LD 15
  • CD4+ 2
  • Sputum: P. jiroveci
  • Progression, need UPV

 

 

 

 

 

 


  • Blood and aspirate: above that CMV
  • PcP + CMV pneumonia –> GCV
  • pO2 decreases despite of FiO2 1,0
  • Tachy-/bradycardia

 

Rx

  • Co-trimoxazol 120mg/kg.d i.v. (p.o.), event. clindamycin/primaquine 4x 600mg + 30mg/d or pentamidin 4mg/kg.d i.v.
  • Steroids (prednisolon 80mg/d)
  • Complications: ventilator pneumonia, CMV pneumonia

 

 

 

 

 

 

Latin quote: Astra non mentiuntur = The stars never lie.

 

 

 


Case No 3

49-year-old female, Epstein's tricuspid valve anomaly, long-term stay in Ivory Coast

  • 2 years of weight loss, night sweats, frequent respiratory infections
  • 2017: month of progression of exertional shortness of breath Lab. CRP 160, PCT norm., LD 18
  • Afebrile, SpO2 86%
  • Contact with HIV+ partner 2011-2013, then HIV neg.(?)

 

 

 

Interstitial pulmonary process, dilatation right heart, hilar adenopathy

 

 

 


  • HIV+, CD4+ 50
  • Sputum - induced: Pneumocystis – PCR, microscopically
  • Dg: Pneumocystis pneumonia

 

 

 

 

 

 


Case No 4

 

45-year-old male, HIV+ dg. a month ago

  • Use of pervitin and THC, HIV+ dg. a month ago, HCV+, k labor. examination did not appear
  • SH: unemployed, residing in social facility Light House of CSAP
  • Comes for lasting hiccup (singultus), no other respiratory and digestive symptoms, afebrile
  • Lab.:
    • BC: leu 9,6 (N seg 91%) Hb 92
    • CRP 92
    • CD4+ 93 (11%)
    • LT: AST 1,3, ALT, ALP, GGT and ALP norm.

 

 

 

Extensive districts of reduced transparency with inhomogeneous rough-spotted texture, that have character of inflammatory infiltrates

 

 

 


  • CD4+ 93 (11%)
  • Sputum: Mycobacterium tuberculosis complex - PCR
  • Pulmonary tuberculosis

 

 

 

 

 

 


Case No 5

 

52-year-old male, HIV+ 8 years

  • 8 years ago dg. HIV + in PcP, improved but subsequent poor adherence, excessive alcohol consumption, CD4+ 250, lower extremities: swelling
  • Presenting symptoms: 2 months shortness of breath, weight loss, subfebrile
  • Physical exam: kachexia, crackles, hepatomegaly
  • Lab.: BC: Hb 56, tr 66, AST and ALT norm., GGT 4.3, albumin 17
  • Abdominal U/S: liver steatosis

 

Tu markers

  • CA125 4x higher

 

Rx

  • Oxacillin, cefotaxime

 

 

Bilateral nodulary lesions with cavitation - susp. tumor metastases or cavitary pneumonia

 

 

 


  • Blood culture: Rhodococcus equi
  • D12: exitus letalis
  • Rhodococcus pneumonia

 

 

 

 

 

 


Case No 6

 

Odynophagia, retrosternal pain, weight loss, thrush

  • Continued to suffer from difficulty swallowing

 

 

 

 

 

 


  • Postinflammatory esophageal stenosis

 

 

 

 

 

 


Case No 7

 

31 year old Indonesian, HIV status unknown

 

  • He worked as a cook in a restaurant with oriental cuisine
  • A week of weakness for which he was examined at an internal clinic, from there sent to the neurological dpt where he was hospitalized
  • A qualitative disorder of consciousness has been developing rapidly
  • On examination: he did not respond to instructions in his native language; left-sided hemiparesis has been cought
  • The condition gradually deteriorated: bradycardia, residues in the NG tube, hyponatremia

 

 

MRI: hemispheral laesion of 6 cm in diameter with mass effect with displacement of median structures by 11 mm; other laesions in the pons, cerebellum and brain peduncles. Dif. dg.: glioblastoma

 

 

 


  • Susp. cerebral toxoplasmosis
  • Terapeutic test: pyrimethamin + sulphadiazin, then because of limited resorption: i.v. clindamycin; dexamethason
  • In the further course, the status was developing without changes in consciousness
  • Slight improvement
    • bradycardia
    • biochemical parameters
    • digestion with NG tube
  • The patient has had tracheostomy and remain spontaneously ventilating
  • The state of consciousness had not been improving - certainly due to the irreversible destruction of brain tissue

 

 

 

 

 

 


Case No 8

 

34-year-old homosexual man, HIV+ known for 5 years

  • At the time of dg. CD4+ 269, he was not treated, but after a year CD4+ 4!, he got PcP, he was cured
  • He took antiretrovirals irregularly
  • After 4 years: confusion, falls
  • During the examination it is not able to perform simple instructions, he has been confused after receiving the result of HIV+, neurologist sent the pt to as
  • Here: signs of severe organic psychosyndrome
  • Lab .: BC leu 3,6, tr 144, CRP and JT border values.
  • CD4+ 21 cells/ul
  • Toxoplasma antibodies – negative

 

 

 

CT: large hypodense lesion of the white matter of the entire frontal lobe on the right and a smaller similar focus on the left

 

 

MRI: massive involvement of the white matter of the supratentorial part of the brain, manifested by a high signal in T2 and FLAIR imaging

 

 


  • CSF: total protein 0.81g /l, cells norm.
  • JCV DNA by CSF PCR at 22 million copies/ml CSF
  • NAAT Toxoplasma gondii in CSF negative
  • Dg.: Progressive multifocal leukoencephalopathy (PML)

 

 

 

 

 

 


Case No 9

 

48-year-old male, HIV+ dg. 2009, ART: TDF/FTC+EFV, CD4+ 1133, VL HIV 0, an. VHB, Lu, CDI

 

  • Sudden abdominal pain
  • Accompanied by his wife
  • Leu 19, CRP 137, AMS 3,2
  • X-ray of abdomen

 

 

 

X-ray of abdomen: pneumoperitoneum (sickles under the diaphragm)

 

 

 


  • Surgical intervention: rectum perforation was found
  • Unconventional sexual practices

 

 

 

 

 

 


Case No 10

 

43-year-old HIV+ male in a registered partnership

 

  • He was caught by his partner making autoerotic activities at home

 

 

 

 

 

 


  • A dildo had to be extracted after anus divulsion under general anesthesia

 

 

 

 

 

 

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© H. Rozsypal, Feb-21-2024