Patient with Multiple Symptoms for Six Years Finally Diagnosed with AIDS

Authors: David Z. Rose, M.D., Navin Kedia, D.O., Vesselin Dimov, M.D., Jesse T. Jacob, M.D., Cleveland Clinic

A 48-year-
old, married, Caucasian male was admitted to the hospital with a chief complaint of “excruciating, knife-like” rectal pain. It was accompanied by moderate rectal bleeding. Over the last nine months, he noted frequent, non-bloody bowel movements, rectal pain, fever, and a 90-pound weight loss.

He was diagnosed with probable Crohn’s Disease and treated with oral mesalamine, prednisone, metronidazole, and ciprofloxacin with some relief.

Past medical history (PMH)

Crohn's disease diagnosed 9 months ago.
Over a six year period, he had been evaluated for assorted symptoms including: diplopia; a papular upper lip eruption, diagnosed as herpes simplex; white oral plaques, diagnosed as thrush; and recurrent hematochezia, diagnosed as hemorrhoid flares.

Medications

Mesalamine, prednisone, metronidazole, and ciprofloxacin.

Social history (SH)

Smoker, 20 pack-yrs

Physical examination

Temperature 38.5 C, heart rate 116 and blood pressure 139/83 mm/Hg.
Chest: CTA (B).
CVS: Clear S1S2.
Abdomen: Soft, NT, ND, + BS.
Rectal: perirectal ulcers and thrush.
Extremities: no edema.

Skin lesions:


Upper lip lesion (click to enlarge the image)


Perirectal lesions

What is the most likely diagnosis?

- Perioral lesion due to herpes simplex?
- Rectal ulcers due to Crohn's disease?
- Immunosuppression due to HIV?

What laboratory tests would you suggest?

CBC: WBC 2.6 k/uL, hemoglobin 12g/dL
Stool cultures: Campylobacter jejuni

Any other tests?

Skin biopsy: gluteal cleft biopsies revealed intranuclear inclusions (herpes simplex virus by immunohistochemistry) and numerous intracellular, acid fast bacilli (Mycobacterium avium intracellulare by DNA gene probe). Cytomegalovirus inclusions were also seen, and serum CMV PCR was 68,263 copies/ml.

What is the most likely diagnosis at this point?

Chron's disease seems less likely in this patient, a colonoscopy was done and it was negative.

HIV test was positive. His CD4 count was 6 cell/uL (3%) and viral load exceeded 400,000 copies/ml.

What happened next?

He was treated with intravenous ganciclovir, oral erythromycin, clotrimazole troches, and prophylactic trimethoprim/sulfamethoxazole. Patient's condition improved and he was discharged home.

In the Infectious Disease clinic two weeks later, he began antiretroviral therapy with ritonavir, atazanavir, tenofovir, and emtricitabine.

After eight weeks of therapy, his CD4 count rose to 47 (38%) and he had a 3-log reduction in his viral load.

Final diagnosis

HIV and AIDS-associated opportunistic infections.

What did we learn from this case?

HIV-associated illnesses can present with a wide variety of symptoms which can be difficult to put together to make a succinct diagnosis.

Sometimes patients present with multi-year history of complaints stemming from several organ systems. In these patients, testing for HIV is especially warranted.

Published: 08/01/2005
Updated: 03/12/2011

5 comments:

  1. This is a good case! Nice work finally making the dx of HIV... but what happened with his wife and did they have children? Where did he get HIV?

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  2. Thanks for the comment! Yes, his wife and children were tested. Luckly, all were HIV negative. It turns out this patient had extramarital homosexual encounters that led to his infection. We discovered this after asking about other risk factors, like transfusions, needlesticks, IVDU and tattoos -- all of which he denied. I presented this case at Cleveland Clinic Internal Medicine Morning Report on Feb 2, 2006. Cardiologist Dr. James Young, in attendance, recommended that although the patient presented with rectal pain and diarrhea, an EKG would be useful. As a baseline EKG, it could serve as a reference in the future to compare against if HIV cardiomyopathy developed -- a possibility in up to 20% of newly diagnosed AIDS patients. -DZR

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  3. HIV testing should have been done far earlier, like 3 years earlier. Doctors have to get past the idea that testing is only indicated for gays and single heterosexuals. I think that because he was a "family man" he was done an injustice by no testing earlier. Of course pat. is going to lie about extra-maritil affairs, especially if they're of the same-sex type.

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  4. Unsure as to why he had been treated for Crohn's without having had a c-scope for biopsies. Also, thrush in a young pt says HIV and immunosuppression until proven otherwise.

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  5. Oral or intertriginous candidiasis do NOT say "HIV and immunocompression until proven otherwise" even in young patients. Ofcourse there should be a high degree of suspicion.

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