HIV

I wanted to write a post on one of our more complicated patients whose medical course is way too complex for me to comprehend (details changed for HIPAA reasons). This is a woman in her 50s with a congenital condition causing developmental delay who was admitted with a simple infection but became profoundly ill with seizures, a-fib with RVR, a PE, and a prolonged ICU stay. Her mental status declined rapidly without a clear cause and the work-up baffled us for a long time. A month after admission, someone sent an HIV test, and she came back positive. The CD4+ count was incredibly low, and this completely changed everything. We now think she has multiple opportunistic infections in her brain: varicella-zoster-virus encephalitis and/or ventriculitis, mycobacterium avium intracellulare, a possible bacterial meningitis, a suspicion of CNS lymphoma, a question of JC virus. Her outcome is dismal, and she's likely to die of these diseases.

I was struck by how late and fundamentally important the discovery of AIDS was in this case. The sad truth is that the patient went to the wrong hospital. If she had gone to SF General Hospital, she would have been routinely screened for HIV. The American College of Physicians recommendations now are to screen all patients over 13 for HIV. I don't know if I agree with this as a general rule, but here it would have helped immensely. The truth is, if we had known earlier, it probably would not have changed the outcome. But to be floundering because we did not consider HIV - even in an older developmentally delayed debilitated single woman - is our fault.