AIDS

Another aspect of infectious disease is the management of HIV/AIDS patients; it makes up a bulk of outpatient infectious disease. Interestingly, I learned that when the AIDS epidemic swept San Francisco in the 1980s, all sorts of physicians got involved, from dermatologists (noticing new unusual skin diseases like Kaposi sarcoma) to oncologists (who were knowledgeable about immunocompromised states) to immunologists and infectious disease doctors. But it is on my ID rotation at SFGH that I really focused on learning HIV. Of course almost all practitioners at the general hospital have an interest in HIV, but the primary care doctors and infectious disease specialists are so passionate about it, it's inspiring.

The last patient I consulted on was a middle aged gentleman who had long-standing HIV, CD4 count of 30, viral load of 80,000, off antiretroviral therapy. He was admitted for an anemia of unclear etiology and when he was being transfused, he had a temperature of 38.5. Although this was most likely a transfusion reaction, blood cultures were drawn that grew 1/2 gram negative rods. Right before antibiotics were started, more blood cultures were drawn that also grew 2/2 GNRs. These speciated as Salmonella, non-typhi, non-paratyphi. Thus, ID was consulted.

Salmonella bacteremia is interesting; it was much more common prior to the era of antiretrovirals, and although it is much more common in HIV with a low CD4 count, people rarely think of it when listing opportunistic infections. Furthermore, Salmonella bacteremia in AIDS often acts like typhoid (Salmonella typhi) with a subclinical course, worsening over time, sometimes with a fever and a rash but not much else. Although Salmonella is exquisitely sensitive to antibiotics, the disease often recurs after the course of treatment. Hopefully this gentleman can be plugged back into care and start receiving antiretrovirals.