Instructions

Name the fluids known to transmit HIV?

2. What is the underlying cause for Jack’s initial confusion, disorientation and inability to remember things?

3. Since HIV infection and fully developed AIDS are not the same thing, AIDS is defined as?


Dazed and Confused

Patients with HIV/AIDS may have peculiar and confusing presentations. Not uncommonly, the first sign may be unusual or ‘opportunistic’ infections. Patients with HIV frequently develop lung infections with Pneumocystis jirovecii which can lead to poor oxygenation of the blood, producing neurological symptoms such as confusion and memory loss.
Jack is not himself. Usually well dressed and articulate, he works as a computer programmer. He developed a cough and fever last week, and two days ago he didn’t show up for work. He didn’t return to his apartment either. In fact, he’s been wandering the streets lost and confused. He can’t remember where his car is or where he lives. Last night he paid for dinner at a local restaurant, walked off and left his wallet. He’s been lost ever since. The police picked him up for vagrancy. He was so out of it that he couldn’t even remember his name. Instead of jail, they took him to a local hospital and dropped him off in the emergency room. Jack is actually a decent and caring person and not the vagrant he appears. In fact, several years ago he volunteered time with an international relief agency in Haiti. Unfortunately he was involved in a serious car accident there and ended up with a ruptured spleen. He received six units of blood during his emergency surgery in Haiti. About six weeks after his surgery, he developed what he thought was the flu, but it passed. He’s been healthy until now


Once at the hospital, an observant nurse in the ER thought Jack looked cyanotic. Using a cutaneous oximeter, she found that Jack’s oxygen saturation was only 68% instead of the nearly 100% it should be. She summoned the doctor who listened to Jack’s lungs and suggested he had pneumonia. A chest X-ray revealed extensive changes in both lungs consistent with Pneumocystis jirovecii. This uniquely opportunistic infection suggested that Jack was showing the first signs of acquired immune deficiency syndrome (AIDS).

Given his seriously low blood oxygen saturation, he was started on supplemental oxygen plus an antibiotic that would combat the suspected Pneumocystis organism. Within a few minutes of starting the oxygen, his color improved and he began to ‘wake up.’ Indeed, Jack had been ‘out of it’ because his blood oxygen level was so low. Jack agreed to a bronchoscopic procedure to obtain some inflammatory material from deep in his lungs. It was loaded with Pneumocystis (little black, caved in soccer balls in the image). A blood test confirmed Jack was HIV positive and that his CD4 cell count was only 85/mm3.
Jack must have become infected with HIV from tainted blood during his emergency surgery in Haiti. Fluids capable of transmitting HIV include blood, vaginal fluids and semen. Had he not had the transfusion, however, he would have died at that time from his injuries. Although Jack was tested for HIV three weeks after his surgery, at that time the test was negative. Sometimes this happens. Screening tests look for certain classes of antibodies against HIV and the levels may not be detectable until as long as six weeks after the initial infection. Jack’s test was probably done too early in the course of his infection, and prior to the appearance of sufficient numbers of antibodies to make it positive. Jack’s test is now positive.
HIV positivity is not synonymous with AIDS, although everyone who is HIV positive will eventually develop AIDS. AIDS indicates immune system failure and is defined as the presence of opportunistic infections, i.e. those that take advantage of a compromised person, and a CD4 cell count below 200/mm3. (A healthy number is 500-1000/mm3). Prevention rests with eliminating, or never starting, risky behaviors, such as unprotected sex and intravenous drug use.

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