Abstract
A 52-year-old Caucasian man presented to hospital with confusion and was treated for a urinary tract infection. He developed new and unexpected signs and symptoms during his stay in hospital. On further questioning, the story of his social background unfolded and, following further investigation, he was diagnosed with human immunodeficiency virus (HIV). This case reminds all clinicians to think about HIV in the older patient and it also gives direction for investigation and management of similar cases in the future. Identifying HIV early is imperative because it allows effective treatment to be initiated and this will impact upon the patient’s quality and longevity of life.
BACKGROUND
This case emphasises the importance of thorough patient assessment, particularly with regards to their social circumstances. It illustrates how signs and symptoms can evolve within the hospital setting and highlights the importance of thinking broadly before settling for a working diagnosis.
CASE PRESENTATION
A 52-year-old Caucasian man was admitted to the medical unit of a busy district general hospital. He looked unkempt, thin and wasted and he carried a pungent smell of urine. He was confused and scored 5 out of 10 on his abbreviated mental test (AMT) examination.
His previous hospital notes documented that he had had a cerebral infarction in 2005 from which he had residual expressive dysphasia. A computed tomography (CT) head scan at that stage had shown an acute infarction in the left posterior cerebral artery region.
He also had type 2 diabetes and hypertension. He didn’t smoke and consumed alcohol occasionally. He was separated from his wife and had three sons in their 20s. He lived a lonely life confined to his one bedroom flat.
On admission, he was apyrexial with stable observations. On examination, he was notably pale and had oral candida. His cardiovascular, respiratory and abdominal examinations were unremarkable.
His urine dipstick revealed the presence of leucocytes and nitrites and he was commenced on trimethoprim. Given that there were obvious signs of neglect, he was admitted to the rehabilitation ward so that a social package could be put in place before his discharge from hospital.
His full blood count (FBC) showed anaemia and leucopoenia. Tests for haematinics showed that the patient had a folate deficiency and his mid stream urine showed a growth of β-haemolytic streptococci sensitive to amoxicillin.
Throughout his hospital stay, the patient was reported to have had diarrhoea which persisted despite having completed a course of antibiotics. A coeliac screen was undertaken in view of this to rule out malabsorption and this was negative.
Several weeks later while still in hospital, it was noted that the patient was having successive temperature spikes. His subsequent blood cultures were negative. He then underwent a number of tonic–clonic seizures over a 3 day period. When he was assessed post-seizure episodes, he was often in a post-ictal state. A positive up going plantar response in his right foot was noted on neurological examination which was otherwise unremarkable.
On further questioning the patient admitted to having had past homosexual relationships, the most recent being several months ago. He denied currently being in a sexually active relationship and also denied engaging in intravenous drug abuse, having tattoos or having received a recent blood transfusion.
INVESTIGATIONS
Given that his FBC suggested immunocompromise, an autoimmune screen was undertaken including tests for blood borne viruses. His hepatitis B and C surface antigen and hepatitis C antibody tests were negative, but HIV serology revealed he was HIV positive.
His cluster of differentiation (CD4) count was notably low (<50 cells/μl). Patients who present with a CD4 count >200 cells/μl are early presenters and those who present with a CD4 count <200 cells/μl are late presenters.1
The new onset of seizure episodes were a suspected consequence of his HIV status. A repeat CT head scan showed a matured left posterior cerebral artery infarction. The whole ventricular system was noted to have increased in size, demonstrating a marked global neurodegenerative process in the space of 2 years. There was also marked brain volume loss compared to the CT head scan of 2005 and this was thought to be secondary to the patient’s HIV status. A magnetic resonance imaging (MRI) head scan was then requested and this ruled out any evidence of opportunistic infection or lymphoma.
TREATMENT
Following consultation with a genitourinary medicine specialist, the patient was commenced on antiretroviral therapy and also started on cotrimoxazole for Pneumocystis carinii pneumonia (PCP) prophylaxis.
OUTCOME AND FOLLOW-UP
The patient tolerated the antiretroviral drugs well and his condition improved. A social care package was organised, the patient having spent several months in hospital, and he was discharged and arrangements for follow-up with an HIV specialist were put in place.
DISCUSSION
There is a broad spectrum of illness associated with HIV infection. Over 60 000 people have been infected with HIV since 1982 in the UK. As this disease gets more treatable, recognising the early phase becomes ever more important.1
Clinicians should think about HIV if there are unusual signs—for example, oral candidiasis, recurrent shingles, a reduced blood count or central nervous system infections. It is essential to obtain informed consent before testing for HIV as this has psychological, social and financial implications.2
HIV is diagnosed by detecting anti-HIV antibodies in the serum, which may not appear for up to 3 months post-infection. Further investigation can be considered depending on individual patient symptoms.
Patients are also prone to immune dysfunction due to the progressive and severe depletion of CD4 lymphocytes. Once a patient has been diagnosed with HIV, their CD4 count is usually measured every 3 months. The total CD4 count provides the best predictor of risk of progression to AIDS or death.3
Antiretroviral drugs suppress viral replication to as low a level as possible for as long as possible. They can be given in combination when there are clear signs that a person’s immune system is reaching dangerously low levels.
Despite the dramatically improved prognosis realised by antiretroviral therapy, late presentation remains a major concern. Often, late presenters tend to be those at lower perceived risk of infection, those who are not routinely offered HIV testing, and are often from marginalised groups.3
Benefits of starting antiretroviral therapy without delay include faster resolution of opportunistic diseases (while still active) and a decreased risk of reccurence.3 Consequently, patients who present late with HIV are often ill, have a high mortality risk, and are less likely to respond to treatment when initiated.
HIV affects many organ systems to include the nervous system, the visual system and also the gastrointestinal tract. Neurological complications of HIV infection are common and are a significant source of morbidity. Other neurological disease associated with HIV infection include cognitive motor complex and peripheral neuropathy.4
The seizures that the patient in this case underwent were thought to be due to Toxoplasma gondii, a parasitic disease which can cause encephalitis and cerebral abscesses in the immunocompromised patient.
Clinical features include focal neurological signs, fits, fever, headache and possible confusion.4 Although there were changes noted on his CT head scan, they were attributed to his previous cerebrovascular event rather than as a consequence of parasitic disease.
The gastrointestinal tract is also a target to numerous HIV associated diseases5 including opportunistic infection and malignancy.6 It also affects the gastrointestinal mucosal immune system. This can lead to HIV enteropathy causing diarrhoea and malabsorption. This may have accounted for this patient’s persistent diarrhoea. Antiretroviral therapy offers new therapeutic options in cryptosporidiosis and microsporidiosis and is crucial for the long term prevention of opportunistic enteric infections of HIV related malignancies.5
Weight loss and anorexia is also often seen in advanced disease. However, in the case of this patient, his wasted appearance was more likely a consequence of self neglect.
While the early diagnosis in those at risk of HIV remains medically important, the short term economic impact is often substantial. It has been shown that direct care costs in the year following HIV diagnosis were more than 20% higher for patients who presented late.3 Subsequently, late presentation means that opportunities to reduced onward transmission, either by reducing high risk behaviour or by reducing an individual’s infectivity, are missed.7
LEARNING POINTS
The early recognition of HIV not only improves patient survival but also reduces the risk to sexual partners as well as to health professionals.
It is imperative not to forget HIV in the older patient.
Footnotes
Competing interests: none.
Patient consent: Patient/guardian consent was obtained for publication
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