Assignment: HIV Infection

Question Description

Lucy Johnson, a 10-year-old girl with HIV infection, presented to an HIV treatment facility in Lusaka, Zambia, with fever, rash, and weight loss.

History

The patient is a 10-year-old Zambian girl who was brought to the clinic in January 2006 by an aunt for evaluation in order to begin antiretroviral therapy (ART). She is thought to have been born with HIV and was diagnosed at a private clinic in another town with a baseline CD4 count of 89 cells/L. (CD4 percentage: 19 percent ). Her previous medical history included growth retardation, recurrent pneumonia, and pulmonary tuberculosis. She didn’t have any known drug allergies.

She reported chronic diarrhea, painful feet, and subjective fevers at her first antiretroviral (ARV) clinic visit. She was afebrile on examination, and her weight (18 kg) was low for her age. Her physical examination revealed a fine papular pruritic rash, conjunctival pallor, crackles at the base of her left lung, and a soft but distended abdomen. Laboratory tests at the time revealed hemoglobin levels of 8.1 g/dL, a white blood cell (WBC) count of 5,800 cells/L, and a platelet count of 409,000 cells/L. Trimethoprim-sulfamethoxazole (TMP-SMX, cotrimoxazole) was prescribed as prophylaxis against Pneumocystis jiroveci pneumonia, mebendazole as empiric treatment of her diarrhea (to cover helminthic infections such as Strongyloides stercoralis), hydrocortisone ointment to suppress her rash, and multivitamins

She returned to the clinic three weeks later, reporting that the diarrhea and subjective fevers had subsided. She’d gained 2 kg, but she

still had a pruritic rash, which was treated with a 2% sulfur ointment. She had not yet begun the TMP-SMX regimen, but had been instructed to do so and to return in two weeks for ART initiation. ARV initiation was delayed at her clinic visit two weeks later due to delays in obtaining laboratory results and the unavailability of her caregiver. She had started and continued the TMP-SMX regimen by this point. Her clinical status improved over the next six weeks, and she maintained a stable weight. During a visit at the end of February, she complained of a persistent pruritic rash as well as recurrent fevers and diarrhea. There are no records of the treatment provided during that visit. A full blood count (CBC) was ordered. She returned in mid-March and reported that the rash and diarrhea had improved. The chart made no mention of fever. CBC results from her previous visit were available at this time:

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3,500 cells/L WBC count
Hemoglobin concentration: 4.4 g/dL
14.7 percent hematocrit
Additional lab results obtained during the patient’s mid-March visit revealed:

5,700 cells/L WBC count
Hemoglobin concentration: 6.8 g/dL
832,000 cells/L platelet count
CD4 cell count: 141 cells/L (CD4 percentage: 7.3 percent )
Alanine aminotransferase (ALT) concentration: 17 IU/L
Aspartate aminotransferase (AST) concentration: 37 IU/L
Creatinine concentration: 20 mg/dL

ARV initiation has been postponed once more. The reasons for ART deferral during this time are unclear, but appear to be a combination of factors, including delays in obtaining the patient’s laboratory results and concerns that she had an underlying opportunistic infection (OI) that needed to be diagnosed and treated before starting ART. In patients with signs or symptoms of an active OI, the clinic treatment protocol postpones ART initiation.

When the patient returned to the clinic in early April, she was afebrile and clinically stable, so she began an ART regimen of nevirapine, lamivudine, and stavudine. Her examination at the time was notable for small (0.5 cm in diameter) papules on her face. The documentation in the patient’s chart does not clearly indicate whether this was a new rash or if she had other symptoms. A molluscum contagiosum presumptive diagnosis was made.

She returned 3 weeks later, complaining of painful and pruritic nodules that had developed shortly after beginning ART, subjective fever, generalized weakness, and body aches.

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