A 54-year-old male, bisexual, retired nurse.
Natural of the Department of Huanuco.
History of frequent trips to their birthplace
Pasatiempo: Epidemiology.
Non-drug user.
Diagnosis of HIV infection in 2000.
In August 2006 she consulted for fever and diarrhea.
No prophylactic medication for OI.
Physical examination revealed cervical and inguinal microadenopathies.
BMI: 23 kg/m2.
Laboratory tests: Inflammatory reaction in faeces: leukocytes > 100/field, PMN (99%), mucus (+++), blood (-).
Coprocultive (-).
Blood count: Leukocytes: 10,300/mm3, Hb: 9.3 g/dL, platelets: 823,000/mm3.
Hepatic tests: Alkaline phosphatase (ALP): 458 U/L, gamma-gluttransferase (GGT): 158 U/L, oxalacetic glutamic transaminase (OGT): 62 %
In June 2006, the CD4 cell count was 108 cells/ mm3 and the HIV viral load was 1,064 543 copies/ml.
After initial therapy and remission of diarrhea, the patient developed intermittent febrile elevations, diffuse colic abdominal pain of moderate intensity.
The study was extended: aspirate and bone marrow culture (-).
Sputum AFB (x3): negative.
Blood cultures were negative.
Abdominal CT: hepatomegaly and absence of gallstones.
HCV antibodies: reactive.
HCV viral load: 1,166 Ul/ml (3,147 copies/ml).
Control tests showed a higher increase in GGT (397 U/L) and FA (1,476 U/L).
Disseminated suspected deep mycosis was initiated with amphotericin (0.7 mg/kg/day); which was administered every other day until the cumulative dose of 600 mg, being suspended by elevation of creatinine to 1.7 mg.
The fever resolved on the tenth day of treatment with fluconazole ev.
Result of sputum AFB culture: growth of a colony.
She was managed conservatively.
During the maintenance phase with fluconazole, fever reappeared, so a lumbar puncture was performed obtaining the following results: glucose: 33 mg/dl, ADA: 5.5 Chinese U/1, protein: 47.4 mg/dl.
A CSF sample was sent for culture of Koch's bacillus.
Liver biopsy was performed on the patient and subcutaneous nodules appeared in the abdominal wall. The result was granulomatous hepatitis.
BAAR (-).
Chest CT: right basal infiltrate.
The probability of a disseminated TBC was determined to start specific treatment, I of the National Tuberculosis Control Program (isoniazid + rifampicin + pyrazinamide + TBmi) decided to increase the anti-tuberculosis drug on the seventh day,
All medication was discontinued.
The patient developed persistent cough and dyspnea and was treated for hospital-acquired pneumonia (ciprofloxacin + ceftazidime) with mild clinical improvement.
Anti-TBC treatment was restarted with the following regimen: streptomycin 600 mg/day + etambucil 30 mg/kg-weight/day, continuing with ciprofloxacin 400 mg/day ev twice daily.
Mycobacterium sp.
A blood sample of the patient was sent to the Institute of Tropical Medicine of the Universidad Nacional Mayor de San Marcos, finding P. bra-siliensis positive in the smear, with negative culture.
A review of the liver biopsy performed previously confirmed fungal liver involvement, starting treatment with itraconazole 100 mg twice daily.
In December 2009, the CD4 count decreased to 19 cells/mm3 and the HIV viral load was 457,500 copies/ml.
The patient continued with mild cough and sporadic abdominal pain associated with increased amylasemia.
Cytomegalovir serology (CMV) was requested: IgG 19.1 Ul/ml, IgM 1.5 Ul/ml (Reactive > 1.1 Ul/ml).
1.
Asymptomatic CMV infection was detected in a control group performed due to the use of full doses of etambu.
A second CMV serology performed one week after the first detected an increase in antibodies to: IgG 36.5 Ul/ml, IgM 2.7 Ul/ml.
The patient was managed conservatively with remission of abdominal pain.
At the beginning of 2007, the patient presented with fevers, continued with mild cough and an increase in creatinine levels was evident.
Due to RAFA of renal type and suspected MDR-TB, moxifloxacin 400 mg/day, 600 mg three times a week, cycloserine 250 mg/day was initiated, continuing with 800 mg capreomycin three times per week.
One month after initiating the individualized anti-TBC regimen, the patient presented symptoms consistent with psychosis.
It was decided to start highly active antiretroviral therapy (HAART) with a National Program (Zelidone night + lamivudine: 1 tablet in the morning and zidovudine + lamivudine + nevirapine: 1 tablet in the evening).
Zidovudine + lamivudine was continued: 1 tablet twice daily.
The patient persisted with severe psychotic symptoms and died of acute liver failure after antipsychotic medication administration.
The result of sputum sensitivity in sputum culture was resistant to isoniazid and rifampicin.
Necropsy was not performed.
