Case Studies

 Case 3.8 Acquired immune deficiency syndrome: persistent generalized lymphadenopathy

A 29-year-old man had a history of fatigue, night sweats and axillary lymphadenopathy for 6 months. Fine-needle lymph-node biopsy suggested a reactive cause rather than malignancy. At a follow-up visit 2 months later he was found to have palpable, non-tender cervical and inguinal nodes and considerable weight loss (8.5kg). Further investigations were done to exclude a lymphoma. Computed tomography scan of his chest and abdomen showed no lymph-node enlargement and no organomegaly.

Immunological investigations are shown in Table C3.8. Full blood counts were normal as was the C-reactive protein level. In view of these findings, he was asked about previous blood transfusions (none) and high-risk activity for HIV infection (three heterosexual partners), counselled and tested for HIV antibody. He was HIV-1-antibody positive. A diagnosis of AIDS was made on the basis of a positive HIV antibody test and weight loss of more than 10% in 12 months.

Viral load measurement showed 46 x 10³ copies of HIV-RNA per millilitre and he was positive for cytomegalovirus infection by PCR. In view of the low CD4 count he was started on prophylactic co-trimoxozole and triple antiviral therapy, namely zidovudine, didanosine and ritonavir. He is being reviewed at 2-4-weekly intervals and monitored with viral load measurements. Case 3.8 emphasizes several important points:

1. Not all patients with HIV present with recognizably HIV-related symptoms or signs.
2. A careful 'high-risk' history is important but not always helpful.
3. If there is a possibility of HIV infection, an HIV antibody test should always be done after appropriate counselling.

Table C3.8 Immunological investigations* in Case 3.8.

*Normal adult ranges shown in brackets.