CASE 1

History:

An 18-year-old noted fever of one week duration along with sore throat, mild diarrhea, headache, and generalized aching. She saw her family physician who noted pharyngitis, generalized lymphadenopathy, and a very mild diffuse erythematous rash on her extremities and trunk on physical examination. The physician suspected an acute viral illness such as infectious mononucleosis, but a monospot test was negative and her symptoms were still present two weeks later. Further history indicated that she had multiple episodes of unprotected sexual intercourse with several partners over the past two months.

Image 1.1

This is a schematic of the life cycle of human immunodeficiency virus.

Image 1.2

This is a laboratory test performed. The patient is lane B.

Questions:

1. What tests should you consider obtaining next?
2. What are the major risk factors for HIV infection?
3. What is the nature of this patient's acute illness?
4. How reliable is the HIV test? What is the result for the patient in lane A in the test above?
5. What is this patient's stage of HIV infection?

CASE 2

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.

Questions:

1. What is the natural history of HIV infection?
2. What HIV-related illnesses does he have?
3. What is this patient's stage of HIV infection?
4. What therapy is indicated?

CASE 3

History:

A 35-year-old man was driving home from work when he suddenly became short of breath. He pulled his pickup truck into the lot of a local hospital and walked with difficulty into the emergency room. His vital signs showed respirations 30, pulse 102, temperature 37.9 C, and blood pressure 110/60 mm Hg. A chest x-ray showed bilateral patchy infiltrates. A bronchoalvoelar lavage was performed. Although therapy was initiated, he died four days after admission.

Image 3.1

Image 3.2

Image 3.3

Questions:

1. What did pathologic examination of the BAL fluid probably show?
2. How could his acute illness have been prevented?
3. What are underlying disease processes that can lead to this acute illness?
4. How would you confirm this?

CASE 4

History:

A 29-year-old woman became increasingly short of breath, with a non-productive cough and low-grade fever. She also had a mild watery diarrhea for the past week. She was also noted to have hypoglycemia and hyponatremia. A chest radiograph showed ill-defined bilateral infiltrates. A stool for ova and parasites was negative. A bronchoalveolar lavage (BAL) with transbronchial biopsy (TBB) was performed. After the results of the BAL and TBB were reported, an HIV test was performed and was positive. A CD4 lymphocyte count was 135 cells/microliter. Further history revealed that her risk factor was a sex partner at risk (a former injection drug user).

Image 4.1

Image 4.2

Questions:

1. What is the stage of her HIV infection?
2. Where else in the body might this infection be found?

CASE 5

History:

A 28-year-old woman developed an increasingly severe headache over a two day period of time and came to the emergency room of the hospital. Vital signs showed respirations 25, pulse 82, temperature 37.4 C, and blood pressure 145/80 mm Hg. Physical examination revealed generalized lymphadenopathy, and needle tracks 2 cm long were noted on the antecubital fossa skin of her left arm. She did not have papilledema. A lumbar puncture was performed which showed increased opening pressure. The cerebrospinal fluid (CSF) obtained was fairly clear. Examination of the CSF showed no RBC's and only a few WBC's, all mononuclear cells.

Image 5.1

Image 5.2

Image 5.3

Questions:

1. What is the diagnosis?
2. How do these findings account for the clinical presentation?
3. What is the significance of the needle tracks in the arm?

CASE 6

History:

A 30-year-old man began to notice the appearance of small reddish-purple patches on the skin of his face and hands. These gradually increased in size and number and then involved the skin of the trunk and lower extremities.

Image 6.1

Image 6.2

Image 6.3

Questions:

1. What diagnosis do you suspect?
2. What laboratory testing should be requested when you suspect such a diagnosis?
3. What findings would you suspect in a clinical history?
4. How often does visceral organ involvement occur in this disease?

CASE 7

History:

A 42-year-old man who had been known to be HIV positive for 10 years developed persistent fever with weight loss. Physical examination revealed hepatomegaly with splenomegaly, and lymph nodes were palpable in the posterior cervical region. A chest radiograph showed no infiltrates or masses. A lymph node biopsy was performed.

Image 7.1

Image 7.2

Image 7.3

Questions:

1. What are the possible causes for these findings?
2. What laboratory testing or diagnostic procedures can be performed to reach a diagnosis?
3. What is his stage of HIV infection?
4. What laboratory testing is available to follow the course of his HIV infection?

CASE 8

History:

A 31-year-old woman was diagnosed with HIV infection 6 years ago but was relatively healthy until a year ago, when she developed oral thrush. A month later she was hospitalized for a respiratory tract infection. Streptococcus pneumoniae was cultured. Her most recent hospitalization followed the onset of a fever to 38 C. She also had a cough productive of sputum that was thick and yellow-tinged. A chest radiograph showed patchy areas of consolidation in both lungs.

Image 8.1

Image 8.2

Questions:

1. What are the possible causes for these findings?
2. What laboratory testing or diagnostic procedures can be performed to reach a diagnosis?