Clinical Immunology & Microbiology

  Case study: Akua is a 29-year old lady form Botswana who arrived in the UK two months ago. She presents at the Teddington Memorial Hospital Walk-In Centre complaining of fever. The fever started 14 days ago, accompanied by muscle pain and nausea. On initial questioning, it becomes apparent that her fever is episodic and is always associated with shaking and sweating. She also looks pale and has lost some weight in the last month. She has not been in contact with anyone with fever and has never had TB. She denies any recent history of diarrhoea, but claims that she once saw something in her stool, which she thought was odd. She occasionally takes OTC analgesics when she has a headache and has no known allergies. She is referred to the Emergency Department for further investigations. A physical examination at the Emergency Department revealed the following: Ø Pale mucous membrane Ø BP: 100/65 Ø Pulse: 120 b/m, regular Ø No skin lesions (petechiae or chancres) Ø Temp: 39Oc Ø Palpable liver and spleen and lymphadenopathy She has no localising cardiovascular, respiratory or gastrointestinal symptoms. Akua is referred to the Communicable Disease Unit for further tests based on suspicion of an infection. The results were as follows: Blood: § Hb: 90 g/L § MCV: 72 fl § WBC: 6.5 x 109 (mostly polymorphonuclear leukocytes) § Platelets: 95 x 109 § ESR: 85 mm/h § Urea: 9.0mmol/L § Creatinine: 82 mmol/L § Glucose: 3.2 mmol/L Liver function test: § Albumin: 30 g/L § AST: 110 U/L § ALP: 75 U/L § Bilirubin (unconjugated): 32 g/L The chest X-ray does not indicate lung pathology. Blood film & culture and stool examination results confirm the presence of an infectious agent. She was treated for her infection and anaemia and she felt better by day four. Her fever also subsided, however her temperature didn’t get back to normal. Four weeks post treatment she is still not feeling quite herself and presents to the clinic again. She has continuing low-grade fever, night sweats, malaise and lymphadenopathy. Considering her symptoms, the health advisor discusses testing for HIV infection. She is tested for HIV and the following day she is told that a second blood sample is needed for testing. Both samples were reported as positive for HIV- antibody. A test for other sexually transmitted infections (chlamydia DNA, syphilis serology and gonorrhoea culture) was negative. A further blood sample was taken for the measurements of CD4 count and HIV viral load. The results were as follows: o CD4+ count: 155 cells/mm3 o Viral load: 255352 copies/ml The health advisor spends some time with Akua discussing transmission of HIV and its effect on the immune system. They also discuss the importance of barrier contraception and post exposure prophylaxis, as well as, the current anti-retroviral therapy. Her last sexual intercourse, which was without using any barrier contraception, was a week before her trip to UK. Akua was offered anti-retroviral combination therapy ‘HAART’ and PCP prophylaxis with Cotrimoxazole.