HIV/AIDS Case Study

Overview

Case studies are excellent ways to apply the skills that have been learned. In this case study, you will
learn about the history, symptoms, and diagnosis of HIV/AIDS.

Directions

Review the case study below and complete the questions.

Case Study: HIV/AIDS

SUBJECTIVE:

Patient’s Chief Complaint:

“I’ve been out of breath and had this nagging, dry cough for about a week now. I don’t have any energy
and now I’ve been running a fever for the past 5 or 6 days. It seemed to hit me really fast and I just
haven’t been able to shake it this week. I just keep getting weaker by the day.”

History of Present Illness (HPI):

M.J. is a 29-year-old white male who tested positive for HIV 2 years ago. He visits the HIV clinic at
regular intervals, usually every 2 to 3 months. His most recent visit was about 2 months ago. He initially
developed drug-resistant HIV on his regimen of zidovudine, lamivudine, and efavirenz. However, his
health and CD4 counts have been stable on his new regimen of tenofovir, emtricitabine, and lopinavir-
ritonavir for the last year.

He presents today with complaints of a persistent dry cough, dyspnea, fatigue, and fever.

Past Medical History (PMH):

Respiratory syncytial virus (RSV) at 7 months of age.

Tested positive for HIV with both ELISA and Western Blot testing, 2 years ago.

Seroconversion to PPD 11 years ago; treated with 12 months of isoniazid (INH) successfully.

Oral candidiasis, resolved with fluconazole 2 years ago, and again 14 months ago.
Perianal ulceration that cultured positive for herpes simplex; treated topically with acyclovir and zinc
oxide ointments, 3 years ago.

Diagnosed with anemia, treated with erythropoietin SQ, 14 months ago.

Cytomegalovirus retinitis in the right eye tested positive for IgG to CMV. IV gancyclovir X 3 weeks.

Recurrent Central Line Catheter infections, treated with gentamicin IV x 10 weeks.

Family History (Fam Hx)

Father: Deceased age 52: Complications from acute myocardial infarction. Also had HTN,
Hyperlipidemia.

Mother: Type 2 Diabetes, Rheumatoid Arthritis.

Social History:

Associate Degree from the local college in park ranger studies.

Homosexual, admitted to engaging in protected anal and oral intercourse with multiple sexual partners
since age 22. One partner died of AIDS-related complications 10 months ago.

He has lived with his 51-year-old mother since diagnosis.

Before his recent illnesses, he worked for 5 years as a forest ranger. Currently, the patient is
unemployed and receives Social Security Disability checks. He often works outside the HIV clinic selling
T-shirts to help pay for his medications and healthcare.

Smoked 3 ppd cigarettes for 10 years prior to quitting 3 years ago (30 pack-years).

Past history of alcohol abuse, cocaine sniffing, and IVDU (heroine).

Immunizations:

Last tetanus over 10 years ago in high school years.

“The last shots I had were my shots as a child.”

Negative for (-): nausea, vomiting, diarrhea, chills, night sweats, headache, productive cough, urinary
frequency or pain, or nocturia, anal pain, constipation, bloody stools, or chest pain.

Positive for (+): loss of appetite with weight loss of “about 5 pounds this past week”, Nonproductive, dry
cough, shortness of breath, “funny bruising on arms”.

Medications:

Dapsone 50mg PO Daily (ran out 3 weeks ago because he did not have enough money to buy)

Tenofovir 300mg PO Daily

Emtricitabine 300mg PO Daily

Lopinavir-ritonavir 400mg/100mg PO BID

Ganciclovir 1g PO TID for retinitis

MVI (Multivitamin)

Acyclovir ointment: PRN for anal lesions

Allergies:

Trimethoprim-sulfamethoxazole: Bright red rash covering torso and face, difficulty breathing.

OBJECTIVE:

Physical Examination

Specific abnormal exam findings in italics.

Vital Signs:

BP 130/87

HR 95
RR 30

T: 102.4 F

Ht: 6 ft, 1 in

Wt: 155 lbs 6 months ago: 168 lbs

General: Thin, slightly anxious, ill-appearing young white male with tachypnea

Neuro: Alert, oriented. Pleasant, but weak. Cooperative.

Negative Kernig’s and Babinski signs

Cranial Nerves II-XII grossly intact. No focal neurological weakness

DTR’s intact, equal bilaterally.

Integumentary: Skin soft, intact, warm, dry.

No rashes, petechiae, or cyanosis

2x3 cm mosaic-shaped, purple ecchymotic lesions noted bilateral arms

HEENT: PERRLA

Fundoscopic exam of the Left eye reveals fluffy, white retinal patches with focal
hemorrhage consistent with CMV retinitis. Right eye

fundoscopy unremarkable

Ears and nose clear

Sinuses nontender

The oral cavity is free of erythema, lesions, exudate, or thrush. Membranes moist

Neck and Lymph Nodes: Neck supple with no masses or appreciable carotid bruit

Mild bilateral cervical lymphadenopathy

Thyroid normal without nodules or megaly

Pulm: Mild axillary lymphadenopathy

Anterior chest is clear bilaterally. No wheezes or rhonchi

No accessory muscle usage or tipod positioning

Heart: Normal sinus rhythm on telemetry

Normal S1, S2 without gallop, murmur, or rubs

No peripheral edema

Abdomen: BS x 4 quads

Soft, Nontender to palpation. No rebound. The patient does have the appendix

No hepatosplenomegaly

Moderate inguinal node lymphadenopathy noted bilaterally

Genital / Rectum: Guiaic stool negative for blood

Anal sphincter tone normal.

No visible rectal or genital lesions on exam

Musculoskeletal: Full ROM with good strength

Neuromuscular tone intact

Grips equal 4/5 strength

Extremities: Nails unremarkable for disease

No peripheral edema or muscle wasting

Lab Test 6 months ago Current

Hemoglobin 13.6 g/dL 10.9 g/dL

Platelets (x103/mm) 376 260

WBC (x103/mm) 3.8 3.9

Lymphs (%) 24.7 18.2

Neutrophils (%) 57.3 67.8

CD4 cells/mm3 308 119

HIV RNA (copies/mL) <500 67,600

CXR

Bilateral diffuse interstitial infiltrates without hilar adenopathy

No consolidation or ghon's nodules

Cardiac silhouette properly located, without cardiomegaly

Sputum Culture: Obtained from ultrasonic nebulizer

Methenamine silver stain (+): (consistent with Pneumocystis infection)

Monoclonal immunofluorescence antibody testing: (+) for Pneumocystis)

1. Identify at least two (2) of M.J.’s risk factors for developing HIV/AIDS disease.
2. Why do you think this patient has been taking Dapsone? (Hint: Consider PMH)
3. Does M.J. have a clinical diagnosis of AIDS? Explain your rationale.
4. Identify at least three (3) of M.J.’s clinical signs from his examination that support a diagnosis of
AIDS-related pneumonia.
5. When compared to 6 months ago, explain your rationale for M.J/’s change in HIV/AIDS lab
values. (What changes do you see in his WBC’s, Neutrophils, CD4 count, and HIV RNA viral load?
What do you think these changes mean-if anything?)