On Difficult Patients
By David A. Wohl, MD – November 18, 2011
Those of us who provide care to people with HIV infection have a sneaky suspicion that our jobs and lives are not like those of health care workers attending to other diseases. Partly it is HIV itself. The sudden emergence, the activist response, the celebrity attention and, more recently, the recognition of the global consequences of the virus – makes HIV truly singular. Call it the Red Ribbon Syndrome. Then there are the patients. Providing care to young men, withering from within, felled by a virus for which we had a name but few treatments, was not easy. But, now, even though we have a formulary of HIV medications bursting with power and potential, most HIV providers would agree that taking care of HIV+ patients has only gotten harder. There are the things you can put not just a finger but a whole hand on: the poverty, substance abuse, mental illness, trauma, chaos and stigma that is at the core of the lives of those now living with HIV. And there are other things too, harder to describe – a nihilism and community wide depression that trims the internal flame of life and the will to live.
I have just completed a brief two weeks attending on the inpatient medicine service here at UNC. What started as an HIV ward is now a general medicine service with an Infectious diseases flavor. Most of those with HIV admitted to the hospital come to us. Of a typical census of, say, 15 patients, about two to three would be HIV+. But, these few patients speak volumes about where HIV has found a safe haven. Here is the story of one:
The other day we admitted a middle-aged woman with severe pain in her left jaw radiating down her neck. She was seen at an outside hospital a month earlier for chest pain and was found to have had a myocardial infarction requiring coronary artery stenting. She was diagnosed with HIV infection 5 years ago. At that time her CD4 was 250/uL and she was prescribed Atripla. She took this medication for only a month and never returned to clinic. Why? She was terrified that her family and community would learn of her HIV. She said she felt she would be judged harshly by these people and would be an outcast. “You know how people are about HIV”, she told me during the initial history and physical.
On examination, she was very thin but lively. Her left jaw was swollen and there was a nasty looking lower molar on that side that was long over due for extraction. There was thrush in her mouth and she had decreased breath sounds at the bases of her lungs. Otherwise, the exam was pretty much unremarkable. She did not have a fever and her oxygen saturation was 98% on room air. ECG showed evidence of her prior MI. A chest X-ray, however, showed nodular densities at the bilateral lung fields, most dense at the lower lobes. A follow-up CT scan was done of her jaw, neck and chest as there was concern for Lemierre’s Syndrome (a mixed anaerobic abscess of the mouth that tracks to the jugular vein, forming clot that can shower the lungs). No abscess or clot was found and the lung portion of the scans revealed multifocal small densities in the lower lobes that were described as tubular and branching. No mediastinal adenopathy was seen.
Her CD4 cell count came back the next day at 66/uL.
The patient was placed on clindamycin IV. Dental was consulted and an extraction of her tooth scheduled. Respiratory isolation was instituted and after sputum was unable to be obtained, a bronchoscopy was performed. Bronchial lavage was sent for bacterial, fungal and mycobacterial stains and culture. Viral culture and PCP direct florescent antibody (DFA) testing was also performed. The diagnosis?
PCP was found on the DFA and on cytology. Oral TMP/SMX twice a day was added. An HIV genotype was drawn and while results of this resistance test was pending, Atripla was re-started. She was discharged with a 2 week supply of her medication, including oral clindamycin, and a follow-up appointment with dental and me in the UNC Infectious Diseases Clinic in 1 week.
The case is instructive in many ways. Foremost, the patient was someone who had suffered considerably since over the past several years due to her fear of disclosure of her HIV infection. He weight plummeted, she developed rashes and thrush and now a painfully infected tooth and PCP. Her MI a month ago may well have also been facilitated by HIV via on going inflammation and low HDL cholesterol. I spent a considerable amount of time with her discussing her fears and ways we could protect her privacy and provide on going HIV care. I think she is committed to care.
Her diagnosis of PCP is also of interest. PCP can present in myriad ways and here we had a patient with minimal pulmonary symptoms and apparently good oxygenation. Her X-ray was concerning for a non-tuberculous mycobacterial infection or fungus to me, but it was plain old PCP. Her toothache may have saved her from a more catastrophic presentation a month from now.
Lastly, the decision whether to re-start HIV therapy and what to use is worth considering. A chorus of studies demonstrate a benefit of antiretroviral therapy (including a better survival) when started earlier rather than later in the course of most opportunistic infections, especially PCP. Her virus may well have developed drug resistance during her initial course of Atripla. But, a genoptype is cooking and there is little risk of re-starting Atripla and modifying in a week or so, if necessary, when the results come in.
I will let you know if she comes to her clinic appointment.