Case Study 7.1 – HIV and Related Complications

A 51-year-old Akashi Chizoba initially presented to the emergency room with a complaint of malaise and fever of several months’ duration. He denies illicit drug use, prescription opioid use or marijuana use was obtained. Physical examination was remarkable for pallor and generalized nontender lymphadenopathy. A needle aspiration biopsy of one of his enlarged nodes revealed a mixed cell population, consistent with reactive hyperplasia. Subsequent laboratory evaluation revealed the patient to be seropositive for HIV by both ELISA and Western blot. A CD4+ cell count was 350/μL. The patient was discharged with an appointment to return to the AIDS clinic, but he was subsequently lost to follow-up. He returned to the emergency room 16 months later, complaining of recurrent fever, persistent dry cough, and dyspnea. The chest x-ray at the time is shown in Image 1. A transbronchial biopsy specimen is shown in Image 2. He was begun on sulfa-trimethoprim with a resolution of his infiltrates and symptomatic improvement. He was discharged for follow-up in the hospital AIDS clinic.

Chest X-Ray

The patient failed to keep his subsequent clinic appointments and presented three months later with recurrent dyspnea, fever, voluminous watery diarrhea, and weight loss. Chest x-ray revealed changes similar to those noted on his previous admission, which again responded to therapy with sulfa-trimethoprim. Diarrhea persisted, and a smear of a stool specimen revealed numerous acid-fast bacilli. His CD4+ cell counts at that time were 190/μL. He was again discharged, to be followed as an outpatient, and told to continue his medications. Over the next several months, the patient’s course was characterized by memory loss, persistent diarrhea, loss of appetite, and continuing weight loss despite antimicrobial therapy. He became progressively confused and withdrawn and required almost constant care from his partner Manuel, and friends. He was found unresponsive one morning and was brought to the emergency room. Examination revealed a markedly cachectic man responsive only to deep pain. Radiographic imaging and characteristic pathologic changes are seen in Images 3 through 5. Funduscopic examination revealed irregular areas of retinal hemorrhage and pale exudate bilaterally (Image 6). Breathing was shallow and labored. While in the emergency room, the patient expired. Attempted cardiopulmonary resuscitation was unsuccessful. Gross findings at autopsy included cachexia (wasting); bilaterally firm, heavy, poorly aerated lungs; markedly enlarged spleen; and large, soft, pale retroperitoneal and mesenteric lymph nodes. Additional significant findings at autopsy were noted in the small bowel (Images 7 and 8); similar changes were seen in the spleen. The colon was also markedly abnormal (Images 9 and 10). Sections of the lungs revealed occasional residual accumulations of frothy, eosinophilic, intra-alveolar exudate and numerous inclusion-bearing cells similar to those present in the colon. Cytomegalovirus retinitis was seen.

1. Can you think of another disease in immunosuppressed patients that may result in demyelination?

2. How does this differ pathologically from HIV-1 aseptic meningitis, which occurs 1 to 2 weeks after seroconversion?