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Case History:

This 40-year-old woman is brought to clinic because of extreme emaciation, cough and dyspnea. She has oral thrush, scattered pustules on the skin, and occasional bouts of diarrhea. Temperature is 39.4 C.

The lungs are difficult to auscultate, and she cannot produce satisfactory sputum. All sputum attempts are AFB-negative.

An HIV rapid test is positive (+). CBC shows 12,500 WBCs with neutrophils 78% and lymphocytes 18%. A chest x-ray shows scattered 2-6 mm. lesions throughout both lung fields. Lesions are denser in the lower lobes.
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What is her total lymphocyte count?
What are the possible causes of her lung lesions?
How will you treat this patient?



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Explanation:

[HIDE]COMMENT: This woman has evidence of miliary tuberculosis and /or pneumocystis pneumonia and / or bacterial pneumonia. Such a critical condition warrants treatment of all three of these diagnoses simultaneously. Give four-drug anti-TB treatment. Give high doses of cotrimoxazole. Give intravenous penicillin until the patient stabilizes. Give her oxygen supplementation and prednisone for PCP if her oxygen saturation is below 70%.

Do not be fooled by the high total lymphocyte count, which most likely, is elevated because of serious bacterial infection. Although she may be severely immuno-compromised from her HIV, she still may be able to muster an elevated WBC due to bacterial pneumonia.

Her prognosis is poor. Do not start ARVs until she responds to treatment for her lung problems. Give good adherence counselling![/HIDE]