Case #1 Answers:
Answer 1
Infectious complications: Pneumocystis pneumonia, tuberculosis (M. T.B. as well
as atypical), community acquired pneumonia (pneumococcus, H. influenzae,
mycoplasma, Legionella), cryptococcus. HIV with infiltrates requires isolation
to rule out T.B.
Answer 2
The 1993 AIDS Surveillance Case Definition are as follows:
1. Bacterial infections, multiple or current
2. Candidiasis of bronchi, trachea or lungs
3. Candidiasis, esophageal
4. Cervical cancer
5. Coccidioidomycosis, disseminated or extrapulmonary
6. Cryptosporidiosis, chronic intestinal (>1 month duration)
7. Cytomegalovirus disease (other than liver, spleen or nodes)
8. Cytomegalovirus retinitis (loss of vision)
9. Encephalopathy, HIV-related
10. Herpes simplex, chronic ulcer(s) (>1 month duration) or
Bronchitis, pneumonitis, or Histoplasmosis, disseminazted or
Extrapulmonary
11. Isosporiasis, chronic intestinal (>1 month duration)
12. Kaposi sarcoma
13. Lymphoid interstitial pneumonia and/or pulmonary lymphoid hyperplasia
14. Lymphoma, Burkitt=s (or equivalent term)
15. Lymphoma, immunoblastic
16. Lymphoma, primary, of brain
17. Mycobacterium avium-intracellulare complex of M. kansaii, disseminated or
extra- pulmonary
18. M. tuberculosis, any site
19. Mycobacterium, other species or unidentified species, disseminated or
Extra-pulmonary
20. Pneumocystis carninii pneumonia
21. Pneumonia, recurrent
22. Progressive multifocal leukoencephalopathy
23. Toxoplasmosis of the brain
24. Wasting syndrome due to HIV
This patient has AIDS by low CD4 count alone, although he may also have PCP
pneumonia.
Answer 3
Patient should have induced sputum for gram stain, DFA for PCP, AFB and
bacterial culture. Bronchoscopy should be considered if PCP stain is negative.
Empiric therapy, in the absence of a definitive diagnosis by gram stain or
culture, should be started for possible PCP pneumonia. Patient should also have
a blood gas performed.
Answer 4
First line therapy is Trimethoprim/sulfamethoxazole for three weeks. If PaO2
< 70, prednisone should be added.
Answer 5
Prophylaxis with TMP/SMX double strength daily is 90 - 95% effective.
Alternative drugs include Dapsone, Atovaquone, and aerosolized pentamidine. A
CD4 count of <200 is associated with marked increase in PCP pneumonia incidence,
as well as a low CD4/CD8 ratio ( <10-20%), prior history of PCP at any CD4
count, rapidly falling CD4 count.
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