Case 3

A 43 year-old physician presents to your office because his HIV test was positive two months previously, at the time of a life insurance evaluation. As a result of the test he revealed his bisexual life experiences to his wife, also a physician, who decided to leave the marriage with the 5 year-old daughter and 3 year-old son. The patient denied fever, any pain, skin problems, diarrhea or weakness. He admitted to anorexia, a 12 pound weight loss over two months and insomnia.

Past history: positive PPD since age 5 and oral HSV since childhood with about 3 recurrences per year. He is on no medications and has no known drug allergies (NKDA).

Physical examination. He is depressed appearing but in no physical distress.
T 36.90C, P 84/min, R 18/min BP 122/80 Wt 87.3 Kg

Examination was normal other than a 1 cm. R supraclavicular and a 0.5 cm L posterior cervical lymph node.

Laboratory evaluations (brought by patient)

CBC: normal

Liver function tests: normal 

Creatinine; 0.9 mg/dl

Questions

2. What would you tell him about his future sexual experiences?

3. Would you offer to refer him for psychiatric counseling?

He returns two weeks later. He admits to feeling depressed; he misses his children; and he still has insomnia. His appetite is improved; his weight is unchanged. He has an appointment with a psychiatrist on the following day. Both of you review the laboratory results.

HIV :  ELISA and WB positive

PPD : negative

Anti HBs : positive

Toxoplasmosis titer :  positive

CD4+ lymphocyte count : % 24, = 306/mm3

HIV RNA level : 8400 copies/ml

5. Would you recommend antiretroviral therapy" Would you use one antiretroviral drug or multidrug therapy?

6. What are the side effects of zidovudine? List one major side effect of didanosine, lamivudine, zalcitabine, stavudine, saquinavir, riconavir, and indinavir. Major toxicities only.

7. Should he receive prophylactic therapy to prevent Pneumocystis carinii pneumonia?