An Aids Patient With Anorexia and Progressive Weakness

Jennifer Bartzcak, MD, Michael E. Hagensee, MD, Julio E. Figueroa, MD

Disclosures

Infect Med. 2002;19(7) 

In This Article

Introduction

A 45-year-old HIV-positive man presented to our AIDS clinic on an urgent basis with a 4-day history of fatigue, nausea, diarrhea, subjective fever with sweating, progressive weakness, and decreased oral intake of both solids and liquids. While in the clinic waiting room, he had an episode of emesis without bile or blood.

HIV infection was first diagnosed 7 years earlier in this patient, and his last CD4 cell count, 1 month prior to admission (PTA), was 189/µL, with a viral load of 111,331 copies/mL. His current illness was not associated with dysphagia, odynophagia, vomiting (before the episode in the waiting room), abdominal pain or cramps, syncope, or loss of consciousness. He also denied having respiratory or urinary symptoms.

His past medical history was primarily related to HIV infection. His disease has been inadequately controlled because of poor compliance with his HAART regimen. He had a history of chronic cytomegalovirus (CMV) colitis beginning 3 years PTA, but he reported that before the present illness he was having just 2 or 3 soft, formed stools per day. Additional infectious illnesses included Candida esophagitis, atypical mycobacterial pulmonary infection, hepatitis B and C, and syphilis. Five years PTA, the patient sustained a gunshot wound to the left side of his chest, necessitating partial pneumonectomy. Polyradicular neuropathy developed 1 year before the patient's admission, and he subsequently required wheelchair assistance.

The patient's history included excessive ethanol intake, cocaine and recreational injection drug use, and sex with men and prostitutes.

Although compliance was questionable, the patient's prescribed medications included gabapentin, 330 mg PO tid; abacavir, 300 mg PO bid; lamivudine, 150 mg PO bid; efavirenz, 600 mg PO qhs; ganciclovir, 1800 mg PO tid; and trimethoprimsulfamethoxazole, 1 double-strength tablet PO qd.

On physical examination, his temperature was 36.9ºC (98.4ºF); pulse rate, 120 beats per minute; respiratory rate, 20 breaths per minute; and blood pressure, 136/50 mm Hg. He had proximal muscle weakness, slow and labored speech, and a fine tremor with the arms extended. A grade 3/6 systolic ejection murmur was present, heard best over the left lower sternal border. Abdominal examination revealed voluntary guarding, periumbilical tenderness, and general abdominal discomfort. Findings on the the rectal examination were normal, and results of a stool guaiac test were negative.

Results of an initial laboratory screen were as follows: sodium, 124 mEq/L (normal, 135 to 148 mEq/L); potassium, 4.1 mEq/L (normal, 3.5 to 5 mEq/L); bicarbonate, 25 mEq/L (normal, 22 to 26 mEq/L); chloride, 103 mEq/L (normal, 96 to 109 mEq/L); blood urea nitrogen, 8 mg/dL (normal, 7 to 22 mg/dL); creatinine, 0.4 mg/dL (normal, 0.6 to 1.3 mg/dL); glucose, 94 mg/dL; (normal, 70 to 115 mg/dL); calcium, 9.8 mg/dL (normal, 8.5 to 10.5 mg/dL); phosphate, 4.5 mg/dL (normal, 2.7 to 4.5 mg/dL); bilirubin, 1 mg/dL (normal, 0.1 to 1.2 mg/dL); alkaline phosphatase, 123 U/L (normal, 30 to 120 U/L); alanine aminotransferase, 27 U/L (normal, 1 to 30 U/L); albumin, 3.2 g/dL (normal, 3.1 to 5.4 g/dL); and lactate dehydrogenase, 233 U/L (normal, 0 to 220 U/L). The white blood cell count was 16,300/µL (normal, 4500 to 11,000/µL), with 48% neutrophils, 37% lymphocytes, 9% monocytes, 4% bands, and 2% eosinophils. Hemoglobin level was 9.1 g/dL (normal, 13.5 to 17 g/dL); hematocrit, 28.1% (normal, 41% to 53%); and platelet count, 277,000/µL (normal, 150,000 to 350,000/µL). A chest x-ray film showed a normal cardiac silhouette, normal pulmonary vasculature, and changes compatible with the patient's previous pneumonectomy, but there was no evidence of active infection.

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