Management of HIV-Positive Patient with Multiple Complications
This patient requires immediate hospitalization and aggressive treatment for suspected CNS infection (likely cryptococcal meningitis or TB meningitis) along with management of other HIV-related complications.
Initial Assessment and Stabilization
- Vital signs: Patient has fever (102°F), tachycardia (125/min), and altered sensorium with neck rigidity and bilateral extensor plantar reflexes indicating meningeal involvement
- Recent history: Recently discharged after PCP pneumonia treatment; now presenting with bleeding per rectum, vomiting, increased urination, abdominal discomfort, and fever
Immediate Management
1. Neurological Emergency Management
- Lumbar puncture: Perform immediately to evaluate for meningitis (cryptococcal, tubercular, or bacterial)
- Empiric antimicrobial therapy:
- Initiate empiric treatment for cryptococcal meningitis with Amphotericin B (0.7-1.0 mg/kg/day IV) plus flucytosine (100 mg/kg/day divided in 4 doses)
- Add empiric coverage for bacterial meningitis with ceftriaxone 2g IV q12h
- Consider TB meningitis coverage with rifampicin, isoniazid, pyrazinamide, and ethambutol
2. Respiratory Management
- Continue Septran DS (co-trimoxazole) for PCP pneumonia prophylaxis and treatment
- Oxygen support as needed to maintain SpO2 >94%
- Chest physiotherapy for left-sided rhonchi and crepts
3. Gastrointestinal Issues
- Evaluate anal swelling and bleeding - likely HIV-related anorectal pathology (condyloma, herpes, or candidiasis)
- Topical antifungal treatment for oral candidiasis with oral amphotericin B suspension 1
- Rehydration therapy with oral or IV fluids for vomiting and increased urination 2
4. Metabolic Management
- Urgent electrolyte panel to address severe hyponatremia (previously 120 mEq/L)
- Correct hyponatremia gradually (not more than 8-10 mEq/L in 24 hours) with IV fluids
- Monitor blood glucose levels due to diabetes and risk of hyperglycemia with ART 2
5. ART Management
- Continue current ART regimen despite acute illness to prevent resistance development 2
- Monitor for immune reconstitution inflammatory syndrome (IRIS) given recent ART initiation and current presentation 2
- Assess for drug interactions between antimicrobials and ART medications 2
Special Considerations
Immune Reconstitution Inflammatory Syndrome (IRIS)
- Patient started ART recently (August 21,2025) and now presents with worsening symptoms
- This presentation is consistent with possible IRIS, which can manifest as paradoxical worsening of opportunistic infections 2
- For severe IRIS manifestations (high fever, altered sensorium), consider short-course corticosteroids (prednisone 60-80mg daily, tapered over 4-6 weeks) 2
Co-trimoxazole Prophylaxis
- Continue Septran DS as it reduces mortality in HIV-infected patients with TB and prevents other opportunistic infections 3, 4
- Co-trimoxazole has shown to reduce the incidence of TB in HIV patients 3
Oral Candidiasis Management
- For resistant oral candidiasis, consider oral amphotericin B suspension as an alternative to azoles 1, 5
- Monitor for treatment response and adjust therapy as needed 6
Follow-up Plan
- Daily neurological assessment
- Monitor electrolytes, renal function, and liver function tests
- CD4 count and HIV viral load testing
- Adjust antimicrobial therapy based on culture results and clinical response
- Evaluate for other opportunistic infections based on CD4 count and clinical presentation 7
Pitfalls to Avoid
- Do not discontinue ART during acute illness as this may lead to viral resistance 2
- Avoid rapid correction of hyponatremia to prevent central pontine myelinolysis
- Do not delay empiric treatment for CNS infection while awaiting diagnostic results
- Be cautious with drug interactions between rifamycins and antiretroviral medications if TB treatment is initiated 2
- Recognize that paradoxical reactions may occur with ART initiation and require management rather than ART discontinuation 2