A 39-year-old man comes to the clinic for voluntary HIV testing. He learned recently that a former sexual partner tested positive for HIV infection and was started on antiretroviral therapy. The patient has been feeling well. He was born and raised in Ecuador and currently resides in New York City, where he works as a nurse at a local nursing home. He enjoys camping and swimming in the pool in his neighborhood. He is the primary caretaker for 2 pet cats and a pet parakeet, all of which are healthy.
Vital signs are normal. Examination shows no abnormalities.
Laboratory testing reveals the following:

Antiretroviral therapy is planned.
The patient is at greatest risk for infection with which of the following organisms at this time?

Question

A 39-year-old man comes to the clinic for voluntary HIV testing.  He learned recently that a former sexual partner tested positive for HIV infection and was started on antiretroviral therapy.  The patient has been feeling well.  He was born and raised in Ecuador and currently resides in New York City, where he works as a nurse at a local nursing home.  He enjoys camping and swimming in the pool in his neighborhood.  He is the primary caretaker for 2 pet cats and a pet parakeet, all of which are healthy.
Vital signs are normal.  Examination shows no abnormalities.
Laboratory testing reveals the following:

Antiretroviral therapy is planned.
The patient is at greatest risk for infection with which of the following organisms at this time?

Quizplus · Accepted Answer

11ec193a_9869_f158_853d_bf4a4a95ee42_MD0002_00 This patient has a new diagnosis of HIV infection potentially contracted from a former sexual partner. He is feeling well and does not have any clinical evidence of an acute infection. His current laboratory results show a CD4 cell count of 730/mm³. At this CD4 level, he would not be at risk for most opportunistic infections, which are usually seen at a CD4 cell count <200/mm³. However, he does have risk factors for tuberculosis (TB), namely his origin from Ecuador and current employment in a health care setting. HIV and TB co-infection can occur at any CD4 level and should be considered in this patient. Testing for latent TB infection (using a tuberculin skin test or interferon gamma release assay) is appropriate. ³ ³ (Choice A) Cryptococcus neoformans is a yeast transmitted through inhalation of bird feces. Despite this patient's risk factor of bird ownership, his risk of disseminated cryptococcal disease, specifically meningoencephalitis, is low due to his current CD4 cell count. (Choice B) Histoplasma capsulatum is a dimorphic fungus that can cause disseminated infection among patients with AIDS. This patient does not have specific risk factors for histoplasmosis, and disseminated disease is typically seen in patients with CD4 cell counts <150/mm³. ³ (Choice D) Pneumocystis carinii (jirovecii) is an environmental fungus that can be inhaled. Primary infection (usually in childhood) is asymptomatic, but in the setting of immunosuppression (eg, AIDS), reactivation can cause severe hypoxemia and respiratory failure. Most cases occur with a CD4 cell count <200/mm³. ³ (Choice E) Toxoplasma gondii is a parasite found in cat stools. When ingested, the oocysts can remain dormant but can reactivate and cause neurological disease in immunocompromised patients. However, this patient's CD4 cell count is above the value associated with toxoplasmosis reactivation, which is usually 100/mm³. ³ Educational objective: Consider tuberculosis (TB) co-infection in patients with HIV infection and appropriate epidemiological risk factors regardless of CD4 cell count. All patients with HIV infection should undergo testing for latent TB infection. __________ References: Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/19357635) Tuberculosis in HIV-infected patients. (http://www.ncbi.nlm.nih.gov/pubmed/15113314)

A 39-Year-Old Man Comes to the Clinic for Voluntary HIV