13: Human Immunodeficiency Virus and Opportunistic Infections

PATIENT PRESENTATION

Chief Complaint

“I’m here for my follow-up visit to start HIV treatment and I’m concerned about these white spots in my mouth. This is the first time I have had them; they don’t go away. I tried to scrape them off and they just come back.”

History of Present Illness

AS is a 25-year-old woman who comes to the family health clinic for her routine HIV care, where she had deferred starting antiretroviral therapy because she “felt fine” and because she was “not sure those drugs work anyway.” Six weeks ago, while on an extended family vacation she was admitted to the hospital with Pneumocystis jirovecii pneumonia. Upon discharge, she saw a physician friend of the family who convinced her to start an antiretroviral regimen. Today the patient complains of white, non-painful, plaques inside her mouth and on her tongue for the past two weeks consistent with oropharyngeal candidiasis.

Past Medical History

HIV diagnosed 2 years ago; risk factor: heterosexual contact

Pneumocystis pneumonia diagnosed 6 weeks ago

History of peptic ulcer 4 years ago, treated with antibiotic therapy and maintained on PPI

Surgical History

None

Family History

Father has hypertension and hyperlipidemia; mother has breast cancer and hyperlipidemia

Social History

Works as a cashier at a grocery store. Single, sexually active with a monogamous male partner, does not regularly use contraception, lives alone. Never smoked, drinks occasionally (2 to 4 drinks per week on the weekend).

Allergies

Sulfa (history of trimethoprim/sulfamethoxazole causing Stevens–Johnson syndrome)

Medications

Atovaquone 1500 mg (10 mL) PO daily

Omeprazole 20 mg PO daily

Physical Examination

Vital Signs

Temp 98.9°F, P 87 beats per minute, RR 13 breaths per minute, BP 125/76 mm Hg, Ht 5′9″, Wt 72 kg

General

Pleasant, pale-looking female in no acute distress

HEENT

Normocephalic, atraumatic, PERRLA, EOMI, visible white plaques on the buccal area and tongue (no plaques seen in throat), poor dentition, L neck lymph node 0.8 cm in diameter

Pulmonary

Effort normal and breath sounds normal

Cardiovascular

Normal rate, regular rhythm, and normal heart sounds

Abdomen

Soft, non-distended, non-tender, bowel sounds normal

Genitourinary

Deferred

Neurology

A&O ×3