Presentation:
H.U., a 57 year old male, presents to the emergency room alone with a
persistent and productive cough lasting over three weeks, sore throat,
oral ulcers, weakness, fever and report of consistent weight loss over
past two years. The patient comes from rural Montana, has not received any
medical care since being hospitalized after a car crash in 1982 (ruptured
spleen and multiple fractured ribs, for which he received 2 units of PRBCs
and has never visited a dentist. He reports that he had to leave his job
as a landscaper 2 years ago because of his constant fatigue, and reports
that the oral ulcers cause him pain when he eats. He is pale, diaphoretic
and emaciated.
Differential Diagnoses:
Infection (systemic, respiratory, or GI)
Tuberculosis
Cancer
HIV infection
Diagnosis & prognosis:
A focused health history reveals that H.U. has experienced 6 episodes of
suspected undiagnosed pneumonia since 1983 and has been “sick for as long
as he can remember.” The physical assessment reveals multiple open,
painful ulcers in the mouth, swollen lymph nodes, bilateral weakness of
all extremities, severe cachexia, and small round, bluish-red lumps the
size of peas all over the inner and anterior thighs. Blood is drawn, urine
and stool samples are taken, and wound cultures are collected from the
oral ulcers. Blood tests reveal H.U. is positive for HIV, and his CD4
count is 7 cells per microliter, well below the cut-off for AIDS (200
cells per microliter). The lumps on his thighs are determined to be
Kaposi’s sarcoma, a cancerous tumor of the connective tissue commonly
affecting persons with weakened immune systems. A sputum culture reveals
TB and a chest X-ray shows extensive damage to the lung tissue, over 75%.
It is speculated that H.U. acquired HIV through his blood transfusions in
1982, three years before HIV antibody testing methods became available to
screen donor blood for the virus. Unfortunately, since H.U.’s CD4 count is
so low and his therapy will be started so late, he does not have a good
prognosis. Current guidelines suggest beginning treatment for HIV when a
patient’s CD4 count is 350 or lower, though other studies support
initiating treatment earlier. It has been found that late diagnoses are
responsible for three quarters of AIDS deaths. Since H.U. will be starting
treatment with a CD4 count of only 7 and almost 30 years of infection, it
is unlikely that his immune system will ever recover. He will most likely
die from one of the opportunistic infections he currently has.
Treatment: – the following treatments were offered to the
patient
Outcome:
Having been told about his diagnosis and prognosis, H.U. chooses to try
everything possible on the treatment list. However, after 3 weeks his CD4
count has dropped to 5, and his condition worsens. He surrenders all
treatment except for the pain medication and palliative care, and 23 days
after his admittance he chooses to return home, where he lives alone. He
will be visited daily by a palliative care nurse who will help him with
his pain medications and ADLs. H.U. is terminally ill, so the palliative
care nurse will make him as comfortable as possible and help him prepare
for a peaceful death.
Case created by Hannah Underdahl, 2011