Case presentation (Dr W Whitely, Dr R F Miller)

A 30 year old white homosexual male presented to the outpatient clinic and was admitted to hospital in early March 2000. He reported an 8 week history of dry cough, 6 weeks of diarrhoea with occasional vomiting, increasing anorexia and malaise associated with weight loss of 8 kg, and night sweats. Ten days before admission he had noted fever and mild bifrontal headaches and for 4 days both he and his partner observed a change in his personality. The patient's symptoms had persisted despite empirical ciprofloxacin prescribed by his primary care physician.

In the past the patient had had hepatitis A in 1990 and was first found to be HIV-1 antibody positive in April 1999, at which time the CD4+ T lymphocyte count was 220 cells ×10⁶/l and HIV viral load was 421 400 copies/ml (Chiron quantiplex b DNA assay v 3.0). An STD screen was negative and he was hepatitis B immune. At the time of diagnosis of HIV infection he had declined HAART as he was asymptomatic but had started co-trimoxazole as primary prophylaxis against Pneumocystis carinii pneumonia. He was subsequently monitored in the outpatient clinic on a regular basis. In late 1999 his CD4+ T lymphocyte count began to fall. By early February 2000 it was 70 cells ×10⁶/l and the HIV viral load was 308 900 copies/ml. The patient began zidovudine 250 mg twice daily, lamivudine 150 mg twice daily, and efavirenz 600 mg at night, 10 days before admission to hospital.

The patient worked in the media, was a non-smoker, and drank alcohol occasionally. He had travelled widely within Europe. Systematic review was non-contributory. Examination on admission showed the patient to be unwell, his temperature varied between 38.2°C and 40°C over the first few hours. The mucosae were pale and oral …