Clinical History:

A 37-year-old man has been known to be HIV positive for the past 6 years, with risk factor of homosexuality. He sees his physician because of persistent diarrhea for the past two months along with persistent fever. He has also lost about 5 kg over the past three months. On physical examination, he is found to have generalized lymphadenopathy, oral thrush, and grouped vesicles on the skin of the left trunk in a dermatomal distribution.

Answers:

1. What is the natural history of HIV infection?

Patients remain asymptomatic for years. They may not even know they are infected and can pass the virus on to others. It is important for physicians to take sexual histories, recognize risk factors, and do HIV testing where appropriate to identify infected persons. In this way, the AIDS epidemic can be reduced in scope and infected persons can be followed and treated appropriately. It takes 8 to 10 years, on average, to develop clinical AIDS, though in some persons AIDS may develop in a shorter time, and other persons may survive much longer (so-called "non-progressors").

2. What HIV-related illnesses does he have?

The constitutional symptoms (fever and diarrhea) are probably related to HIV infection. Likewise, the oral thrush (superficial candidiasis) and Herpes zoster of skin are typical findings. The lymphadenopathy is typical for persistent generalized lymphadenopathy (PGL). His weight loss is typical for someone with a chronic illness, but is not as severe as the wasting syndrome diagnostic of AIDS.

3. What is this patient's stage of HIV infection?

The appearance of these illnesses places him in Stage B. If a CD4 lymphocyte count were obtained and was between 200 and 500 cells/microliter, he would be in Stage B2.

4. What therapy is indicated?

Highly active antiretroviral therapy (HAART) is effective in slowing the immunologic deterioration seen with HIV infection. Antiretroviral therapy is complex. If the dosages are not taken regularly or on schedule, then the thousands of dollars that the medications cost is lost, and not only will HIV infection advance, but resistance to the drugs will more likely occur. The most typical starting regimen includes usage of two nucleoside reverse transcriptase inhibitors (such as zidovudine and didanosine) plus a protease inhibitor (such as ritonavir). Successful drug therapy is indicated by suppressed plasma HIV-1 RNA levels. A rise in the levels may require switching to an alternative drug regimen.