1. CASE 4 54 yo man HIV negative In serodiscordant relationship with untreated HIV positive man…ongoing frequent unprotected sex

2. CASE 4 DATE CD4CD4/CD8HIV test result 04/04690/28%0.60negative 05/05575/29%0.56negative 04/06600/28%0.51negative 06/07550/29%0.56negative 07/08570/27%0.53negative 08/09510/26%0.50negative

3. CASE 4 January 2010 Found to have enlarging rt tonsillar lesion similar to oral hairy leukoplakia despite remaining HIV negative Cause?...What would you do?

4. CASE 4 Biopsy reveals HPV related squamous cell cancer! treated with chemo and radiotherapy ending in September 2010

5. CASE 4 DATE CD4CD4/CD8HIV test result 01/12330/21%0.35negative 03/12240/18%0.25negative 04/12190/16%0.21negative Cause?...What would you do?

6. CASE 4 Idiopathic CD4 T lymphocytopenia? HIV with occult strain with negative conventional test? Other immune disorder? Not likely due to persistent leukopenia due to chemo or radiotherapy

7. CASE 4 Blood to be sent to NIH for specialized HIV testing…ie PBMC culture/DNA testing Also will look at CD8 activation markers and B cell immunity TMP/SMX initiated for PCP prophylaxis

8. CASE 4 It is intriguing to ascribe HPV related cancer in part due to worsening immune deficiency over time…ie an opportunistic malignancy???