Case Records of the Hospital Nacional, Puerto Barrios: A 28 year-old man With Cough and Fever, 2 Weeks After Starting Antiretroviral Medicine
Sr. L is a 28 year old man who lives in Eastern Guatemala. He was well until the fall of 2006, when he began to lose weight and feel weak. He also noted fevers and watery diarrhea. He did not have a cough. He went to a neighborhood doctor, who took blood for lab tests. Results of initial labs showed WBC 9,100 (55% PMS, 42% lymphs, 3% Eos), Hg 9, Hct 28, AST 64, ALT 63. A stool study was positive for Entamoeba Histolytica. Three sputum smears were negative for AFB. Rapid HIV test was positive. He was referred to the MSF clinic, Hospital Nacional, Puerto Barrios.
We saw him for the first time on Oct 9th. He recounted the history outlined above. He has no other past medical or surgical history. He takes no medicine. He has no known allergies. He lives with his wife, who is pregnant, and 7 year old son. He is currently unemployed; he used to work as a salesman. He used to drink beer every day, but stopped when he found out he was HIV positive (one week before he came to our clinic). He does not use drugs or smoke tobacco. Reviews of systems was otherwise unremarkable. His exam was notable for a young man who appeared thin, but not acutely ill. His weight was 43 kgs, height 158 cm (BMI 17), pulse 92 and he was breathing comfortably. His conjunctiva were pale pink and nailbeds pale: he had oral thrush. His thorax and cardiovascular, and abdominal exams were normal.
Our initial impression was a 28 year old man with AIDS (CDC stage B), anemia, mild transaminitis, and Entamoebia Histolytica. We ordered a CD4 count. Our lab cannot do any tests that are not listed above. We follow the Guatemalan National Protocol for TB screening (they do not screen for latent disease). We started him on 1 double strength TMP-SMX daily (PCP prophylaxis) and Metronidazole 500 mg q8 for 14 days (E. Histolytica treatment).
He returned for a follow-up visit three weeks later. He did not have any new complaints. His CD4 count came back at 160. He was seen by the social worker and psychologist, and was approved by the Committee for Anti-Retroviral therapy. In mid-December, we started him on Nevirapine, 3TC, and D4T. He continued Trimethroprim prophylaxis, and reported adherence to this therapy.
He returned two weeks after starting Antiretrovirals complaining of a productive cough, fever, and shortness of breath on exertion for 1 week. He denied diarrhea and other GI and cardiac symptoms. His weight was 44 kgs, temp 37,5 degrees C, pulse 112, and RR 22. His lung exam was notable for few scattered crackles bilaterally, bases more than apexes. His Chest X-ray is shown above.
Ideas? Differential Diagnosis? I thought it might be interesting to compare what the work-up would be in an academic center in New York verses Puerto Barrios, where diagnostic tests are limited (to say the least). What says my Director of ICU Megalopolis Academician Geniusy Amigita Lolita?