AIDS

A 25 year old man who has never seen a doctor presents with a year's worth of symptoms. He's had weight loss, diarrhea, fatigue, and shortness of breath. This last symptom was what finally convinced his sister to force him to the emergency room. Over the last month, his shortness of breath has been progressing rapidly. He has fever, night sweats, and a nonproductive cough. On evaluation in the emergency department, he is noted to be in severe respiratory distress. His oxygen saturation is 89%, and on minimal movement, it drops down to the 70s. Although he is quickly put on oxygen, his need escalates and he is eventually intubated. He is transferred to the intensive care unit. His chest X-ray shows widespread bilateral infiltrates in the lungs.

I had a suspicion, as I had seen this presentation as a medical student. I sent off an HIV test, and it came back positive. His T-cell count was 20. I was convinced this was Pneumocystis jiroveci pneumonia (when I was a medical student, this was called Pneumocystis carinii pneumonia). The presentation, chest X-ray, and clinical picture all pointed to it. I sent off the appropriate tests, supported him clinically, and consulted our infectious disease specialist.

How surprised we were when we found it was not Pneumocystis pneumonia! But the diagnosis wasn't any better; the cultures grew back three separate bugs: Klebsiella from the lungs, and both Staphylococcus and Salmonella from the blood. He was in full-blown septic shock and acute respiratory distress syndrome.

For the next two weeks, he was the sickest patient on the service. Each day, I met with the sister, knowing that could be the day he might die. He was the first patient I saw when coming in and the last patient I checked before leaving. He was being oxygenated with 100% oxygen and a PEEP of 15, and his oxygen saturations were barely adequate. We even had to give paralytics for a few days. There has been extensive research on acute respiratory distress syndrome, but unfortunately, very few things work. I tried everything I could think of; we even considered prone positioning, but by that time, he was on continual dialysis, and it wasn't possible. Finally, I put him on inhaled nitric oxide, a rescue therapy used mainly in right sided heart failure, but I hoped it might match pulmonary blood flow and oxygenation better. Over a period of weeks, his lungs finally recovered; he eventually had a tracheostomy because by that time, he was quite debilitated.

His other organs took a hit, but made it through. As you might expect with an immunocompromised septic patient, he needed three pressors, pushes of bicarbonate, continuous dialysis, artificial nutrition, transfusions (for bone marrow suppression leading to pancytopenia), and a lot of antibiotics. But in the end, his heart, kidneys, and liver recovered. He suffered no cognitive impairment; he was headed to rehabilitation.

This patient was a real save. I never expected to see full-blown AIDS with three opportunistic infections in a community ICU. But I also felt ready to handle such a challenging case. This is why I went into critical care.