General: female patient, 48 years old, Han Chinese.
Complaint: fever for 4 months, headache for 2 months, cough for 1 week.
History: previous history of impure sexual intercourse; patient developed fever with no obvious cause 4 months ago, temperature fluctuated between 38-39 degrees, occasionally 40 degrees, night sweats, wasting, weight loss of more than 10 kg, skin papules after mosquito bites were difficult to fade, anti-HIV (+) was checked at the local CDC, confirmatory test was positive, CD4+ T cells were 56/ul, treated at the local county hospital 2 months ago the patient developed headache and dizziness, accompanied by herpes in the left axilla and left back, diagnosed as herpes zoster in the local hospital, treated with acyclovir for 1 month, then the temperature was normal for 2 days, the local CDC gave zidovudine + lamivudine + nevirapine anti-HIV treatment, after that acyclovir After 1 month of further treatment, the patient still had persistent fever, night sweats, headache, dizziness, and significant skin pain on the affected side. 1 week ago, the patient developed cough, sputum, nausea, and vomiting, and came to our hospital for further treatment. The first physician saw the patient and described as follows: the patient complained of persistent fever, headache, dizziness, weakness, nausea, vomiting, inability to eat, unbearable pain in the affected skin, examination: herpes in the left axilla and left dorsal skin, local breakdown, white spots visible on the tongue and oral mucosa, scrapeable, neck resistance (+), several swollen lymph nodes the size of soy beans can be palpated in the neck, moveable, no tenderness, coarse breath sounds in both lungs. A dry and wet large stall could be heard (-), an ascites sign (-), pathological signs and meningeal stimulation signs (-). Combining the patient’s medical history, symptoms and signs, the patient was considered to be diagnosed with advanced AIDS combined with opportunistic pathogenic infections and admitted to the AIDS department of our hospital for further diagnosis and treatment. Xiao Jiang, Beijing Ditan Hospital Infectious Diseases Treatment Center Past history: denied history of hypertension, coronary heart disease, diabetes mellitus, diagnosed syphilis, denied history of other infectious diseases, denied history of food allergy, denied history of surgical trauma, allergic to cephalosporin.
Family and personal history: no special.
Preliminary analysis: 1, previous history of impure sexual behavior, 4 months ago found anti-HIV (+), consider HIV infection, local hospital check CD4 + T is 56, 4 months ago night sweats, wasting, weight loss of more than 10 kg, 2 months ago appeared herpes zoster, consider the patient is currently entering the AIDS phase. 2, the patient has fever, night sweats for 4 months, cough, cough sputum for 1 week, physical examination: both lungs breath sounds coarse The diagnosis of herpes zoster is clear. 4. syphilis: the patient had a history of unclean sexual intercourse and was clearly diagnosed with syphilis in the past. The diagnosis of syphilis was established. 5. Oral fungal infection: The patient had white spots on the tongue and oral mucosa, which could be scraped off, and the diagnosis of oral fungal infection (thrush) was considered. 6. Headache cause to be investigated: The patient was clearly diagnosed with AIDS, the organism was immunocompromised, and now there was persistent headache and dizziness, and the central system was considered to have an opportunistic pathogenic infection. The patient’s fever, night sweats, and weight loss cannot be excluded from tuberculosis, and the possibility of tuberculous meningitis cannot be ruled out; the patient has developed herpes zoster in the past two months, and the immunity of the body is low. The patient’s previous syphilis could not be ruled out.
Treatment.
The patient was admitted to the hospital to complete laboratory tests, the results indicated that the blood routine: white blood cells 2.08×10E9/L, neutrophil percentage 63.17%, neutrophil count 1.31×10E9/L, red blood cell count 2.22×10E12/L, hemoglobin 68.6g/L, platelet count 200.9×10E9/L liver function: alanine aminotransferase 19.5 U/L, portal aminotransferase 17.3 U/L, total bilirubin 14.9umol/L, direct bilirubin 3.6umol/L, albumin 35.2g/L; electrolytes: potassium 3.92mmol/L, sodium 132.1mmol/L, chloride 96.9mmol/L, urea 4.75mmol/L, creatinine 49.6umol/L; T cell subsets suggested CD3+CD4+ 15cells/ul; ESR 99mm/hr; blood pathogen tests suggested cryptococcal antigen (-); TB antibody (-); varicella antibody IgM (-); EBV-IgM (-); TORCH (-); CMV-IgM (-), syphilis TPHA (+), RPR (-). Lumbar puncture cerebrospinal fluid tests showed protein 35.2 mg/dl, sugar 6.9 mmol/L, chloride 124.9 mmol/l; 300 total cells, WBC 80, cerebrospinal fluid antacid staining and cryptococcal antigen (-); EKG suggested sinus velocity; ultrasound suggested coarse echogenicity of liver parenchyma; liver cyst; no ascites; chest enhancement CT suggested multiple nodular lesions in both lungs, TB, mediastinal lymph nodes The enhanced CT of the chest suggested multiple nodular lesions in both lungs, tuberculosis, mediastinal lymph nodes, and liver cysts; the enhanced CT of the skull suggested bilateral parietal lesions and considered intracranial infection.
After admission, the patient continued anti-HIV treatment with zidovudine + lamivudine + nevirapine; thymopentin to improve body immunity; the patient used acyclovir to treat herpes zoster virus in outside hospital for 2 months, but herpes zoster persisted, considered acyclovir resistance, changed to anti-herpes virus treatment with sodium fosfomate 90mg/Kg Q12hr; because the patient was allergic to cephalosporin antibiotics, added azithromycin 0.5 Qd anti-pulmonary bacterial infection treatment; fluconazole sodium chloride 0.2 Qd anti-oral fungal infection, perfect lumbar puncture suggests cerebrospinal fluid pressure 250mmH2O, lumbar puncture cerebrospinal fluid laboratory tests suggest protein 35.2mg/dl, sugar 6.9mmol/L, chloride 124.9mmol/l; total cells 300, WBC 80, cerebrospinal fluid antacid staining and cryptococcal antigen (-), the results The results showed that the cerebrospinal fluid biochemistry was normal, WBC was mildly increased, viral meningitis was considered, cranial enhancement CT suggested bilateral parietal foci, intracranial infection was considered, sodium fosfomate 90mg/Kg Q12hr also had the effect of treating viral meningitis, and mannitol 250ml Q6hr was used for dehydration. Fever, night sweats, headache and temperature still fluctuates between 38-39 degrees.
We suggested the patient to perfect fiberoptic bronchoscopy, but the patient could not tolerate it and gave up halfway. Enhanced CT of the chest suggested bilateral pulmonary tuberculosis, enlarged mediastinal lymph nodes, lymph node tuberculosis, considering opportunistic pathogenic lung infection also including pulmonary tuberculosis, so we added Rifaximin 0.2 Q12h, Isoniazid 0.3Qd, Rifampin 0.45Qd, Pyrazinamide 0.5Tid, Ethambutol 0.75Qd Anti-tuberculosis treatment, the patient was treated locally with zidovudine + lamivudine + nevirapine for anti-HIV treatment. 38-39 degrees.
The patient continued to be febrile, and on examination: the breath sounds were coarse in both lungs, and a dry and humid stall of 9 yangshang could be heard, with 2.08×10E9/L, 63.17% neutrophils, and 99 mg/L CRP. The cause of the fever was considered to be uncontrolled pulmonary bacterial infection. However, the patient’s temperature still fluctuated between 38-39 degrees with headache, dizziness, and occasional chest tightness and breathlessness, but the oxygen saturation was normal.
The patient continued to have fever and headache after admission, and we took into account the possible viral and tuberculous meningitis during the treatment. The patient was treated with azithromycin 0.5 Qd and cotrimoxazole 2 tablets Q6hr. The patient’s body temperature gradually decreased to normal and the headache and dizziness gradually subsided.
Final diagnosis: AIDS Pulmonary infection Tuberculosis Lymph node tuberculosis Herpes zoster Oral fungal infection Cerebral toxoplasmosis Syphilis Liver cysts Discussion.
Foreign studies have shown that AIDS combined with various opportunistic pathogenic infections mainly occurs in patients with CD4+ T-cell counts below 200 cells/ul. In this case, the patient’s CD4+ T-cell count was 15 cells/ul, suggesting that the body’s immunity is extremely low and easily complicated by various opportunistic pathogenic infections. The patient was admitted with complaints of fever, cough, night sweats and headache and dizziness; therefore, we first considered the presence of pulmonary infection and neurological lesions.
1. New advances in the diagnosis and treatment of AIDS combined with pulmonary opportunistic infections.
Late HIV combined pulmonary infections mainly include bacterial infection, Pneumocystis pneumonia, tuberculosis, cytomegalovirus infection, and fungal infection. In this case, the patient had fever, cough, and sputum before admission, and dry and wet could be smelled in both lungs on examination.
The risk of progression of latent tuberculosis to active tuberculosis increases 100-fold in HIV infection. CD4+ T cells in HIV-infected patients can be combined with tuberculosis at any level, but clinical manifestations vary with CD4+ T cells: CD4+ T cells greater than 350 cells/ul present with typical tuberculosis manifestations, i.e., infiltrative lesions and cavities in the upper lobe. CD4+ T cells less than 50 cells/ul, extra-pulmonary TB is common, and if lymphatic TB is present, chest radiographs are often not significantly positive, but CT suggests lower and middle lobe involvement and corn-like nodular shadowing without cavity formation. PPD tests are often negative in patients with HIV-associated tuberculosis because the body is immunocompromised and cannot induce cellular immunity. To confirm the diagnosis of pulmonary tuberculosis in these patients, in addition to chest-enhanced CT, sputum smear with antacid staining and fiberoptic bronchoscopy with cytopathological examination can also confirm the diagnosis of pulmonary tuberculosis if the sputum or alveolar lavage fluid is positive for cellular antacid staining.
Pneumocystis pneumonia: is a common opportunistic pathogenic infection of AIDS, manifested as acute or subacute onset, progressive dyspnea, cough, no sputum, fever, chest pain within a few weeks or days, not accompanied by pulmonary large-format maple a frightening display sniping sweet cup ditch bald head smell – arterial oxygen partial pressure difference increases, perfect bronchoscopic alveolar lavage sent cytology pathology examination can be clearly diagnosed, the patient in this case did not see dyspnea in the course of the disease, but the patient could not tolerate it. The patient’s oxygen saturation was also normal, but still needed to perfect the bronchoscopy to clarify the diagnosis, but the patient could not tolerate it and gave up. AIDS patients with CD4+ T cells less than 200/ul need to routinely use cotrimoxazole 2 tablets Qd to prevent pneumocystis pneumonia.
Cytomegalovirus pneumonia: often occurs in AIDS patients with CD4+ T cells less than 50/ul, often coexisting with Pneumocystis pneumonia, because the body is immunocompromised, CMV-IgM is often negative, so the presence of cytomegalovirus pneumonia needs to be clarified by CMV-DNA examination, the patient in this case had a negative CMV-DNA examination, excluding cytomegalovirus pneumonia. Pulmonary fungal infections such as Aspergillus infection are also common in AIDS patients. No wedge-shaped lesions were seen on chest enhancement CT, so pulmonary fungal infections were not considered for the time being.
2. New advances in the diagnosis and treatment of AIDS combined with neurological lesions.
AIDS combined with central nervous system lesions include cryptococcal meningitis, tuberculous meningitis, cytomegalovirus encephalitis, toxoplasma encephalopathy, neurosyphilis, progressive multifocal cerebral leukomalacia, etc. In this case, the patient was clearly diagnosed with AIDS, the organism was immunocompromised, headache and dizziness persisted, and opportunistic pathogenic infection of the central system was considered. Lymphatic tuberculosis, lumbar puncture cerebrospinal fluid tests indicated normal protein and chloride levels and increased sugar levels; 300 total cells, 80 WBC, antacid staining of cerebrospinal fluid (-), and no relief of headache and dizziness with the use of anti-TB drugs for tuberculosis, so tuberculous meningitis was not considered.
Cryptococcal meningitis is a common opportunistic pathogenic infection in patients with advanced AIDS and is easily seen when CD4+ T cells are less than 100 cells/ul. It is characterized by headache, dizziness, significantly higher cerebrospinal fluid pressure, increased cerebrospinal fluid protein, significantly lower sugar and chloride levels, and a positive rate of cryptococcal antigen testing in serum and cerebrospinal fluid greater than 95%. The patient’s serum and cerebrospinal fluid were negative for cryptococcal antigen.
The patient has had cutaneous herpes zoster for the past two months and has a low immune system, which does not exclude varicella-zoster virus invasion of the nervous system, but the patient has not experienced relief of headache and dizziness after treatment of cutaneous herpes zoster with ganciclovir at an outside hospital or with sodium phosphonate at our hospital, so viral meningitis is excluded.
The patient had previous syphilis, and the patient’s blood tests indicated syphilis TPHA (+) and RPR (-), suggesting only a negative syphilis infection and not a diagnosis of neurosyphilis.
AIDS combined with toxoplasmosis encephalopathy often occurs in patients with less than 100 CD4+ T cells/ul, and the vast majority develop from latent infection. The clinical features of the disease are fever, headache, confusion, and focal neuropathy. The diagnosis was based on brain-enhanced CT suggestive of intracranial circumferential enhancement and effective empirical treatment. In this case, the patient was admitted to the hospital with enhanced CT brain suggesting biparietal lesions, intracranial infection was considered, and no circumferential enhancement was found; however, 1 month later, the CT was repeated to suggest circumferential enhancement, multiple intracranial occupancies with edema, and Toxoplasma gondii infection was considered.