NYU Medical Grand Rounds Clinical Vignette Matthew B. Brown M.D. PGY-2 10/4/11 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

The patient is a 50 year old man presenting to Bellevue clinic, complaining of unintentional weight loss, fatigue and malaise for the past year. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

The patient was diagnosed with HIV at an outside clinic in 1989; He never received treatment with ART. One year ago, he experienced the onset of progressively worsening weight loss and fatigue. During this time, he was treated for recurrent skin infections and soft tissue abscesses. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Additional History Past Medical History: Shingles, Thrush (2009) Past Surgical History: No history of surgery Social History: Pt. denies any history of ETOH or tobacco use High school teacher; lives in Brooklyn with family Remote unprotected sex with men and women Currently monogamous with his wife, uses protection Family History: No pertinent family history Allergies: No known drug allergies Medications: No medications U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Physical Examination General: Thin-looking middle aged male, comfortable appearing Vital Signs: T: 98.0 BP: 108/65 HR: 90 RR: 16 and O2 sat: 100% RA Exam notable for mild thrush on the surface of the tongue, as well as scattered, small axillary lymphadenopathy L > R, non-tender Remainder of Physical Exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Laboratory Findings CBC: WBC ^9/L, Hgb 10.6 g/dL (14- 18), Plts ^9/L, MCV 89.9 Fl Basic Metabolic Panel: BUN 16 mg/dL, Cr 1.0 mg/dL, normal electrolytes Total Protein 9.1 g/dL ( ), Albumin 3.9 g/dL ( ), otherwise normal Hepatic Panel CD4 Count, HIV Viral PCR, HIV Genotype were also ordered U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Other Initial Visit Tests Patient screened for the following: Syphilis (RPR) -> negative TB (Serum Quantiferon) -> negative GC/Chlamydia (Urine DNA) -> negative Hepatitis B (serum Ag, Ab) -> immune Hepatitis C (serum Antibody) -> negative U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

At the time of his initial clinic visit, the patient was diagnosed presumptively with AIDS (CD<200), WHO Clinical Stage III Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

The patient was started on Bactrim for PCP prophylaxis Additionally, he was prescribed a 14 day course of Fluconazole to treat his thrush He was offered Influenza, Pneumonia, Tdap, and HBV Vaccinations Clinical Course (Initial Visit) U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Diagnosis of AIDS confirmed CD4 Count: 86 (14%) HIV Viral Load: >100,000 copies/ml HIV Viral Genotype: Wild Type ( RT: R211G), (PR: L63P, I64V, V77I ) Patient’s thrush had resolved after completing course of Fluconazole Patient initiated on ART with Atripla Clinical Course (Second Visit) U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

The patient tolerated Atripla well with minimal side effects Within one month, CD4 331 (22%); VL <500 By July 2011 (4 months after initiation of ART), CD4 429 (25%); VL <50 Clinical Course (Subsequent Visits) U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

HIV/AIDS and oral candidiasis, with reconstituted CD4 and undetectable viral load after initiation of HAART. The patient continues to follow closely in the Bellevue virology clinic. He has gained back more than ten pounds of his weight loss, has returned to his teaching job and continues to do well. Final Diagnosis/Summation U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS