Case Report 5

By Humaiyun Sabih, Bilal Asad and Hamzah Younus

Case
A 29-year old man had a history of fatigue, night sweats, and axillary lymphadenopathy for six months. Fine needle biopsy suggested a reactive cause rather than malignancy. At a follow up visit two months later he was found to have palpable, non tender cervical and inguinal nodes and considerable weight loss (8.5kg). Further investigations were done to exclude a lymphoma. Computed tomography scan of his chest and abdomen showed no lymph node enlargement and organomegaly

 29-year old man Sexually active? Possibly syphilis? History of sexual partners, drug abuse?

Syphilis
Primary Syphilis ruled out due to timescale. Secondary Syphilis Fever, malaise, pharyngitis, lymphadenopathy, maculopapular rash. Condylomata lata on genital areas and oral ulcers. Can co-exist with HIV VDRL positive Treponema pallidum haemagglutination test positive

Infections
Diagnostics to exclude infection as the cause of the lymphadenopathy: Pharyngitis, conjunctivitis, upper respiratory infections , cat-scratch disease, TB, etc. Common cold and influenza? tests to exclude these. Blood cultures, swab tests,etc

Infectious mononucleosis
Fatigue and lymphadenopathy, splenomegaly, hepatomegaly Epstein-Barr virus Spread via saliva Confirmed by a serological test. Monospot test(heterophile antobody test)(igG and IgM tests more recently) Presence of 50% lymphocytes with atleast 10% atypical lymphocytes (large, irregular nuclei)

EBV
illness with fever, lymphadenopathy, pharyngitis, and maculopapular rash. EBV: IgM serology and Paul Bunnell positive.

CMV
lymphadenopathy, rash, and splenomegaly CMV serology positive.

Tuberculosis
Sufferers exhibit: lymphadenopathy, along with night sweats, fatigue and significant weight loss. Caused by Mycobacterium Tuberculosis Transferred by infected droplets expelled by an infectious lung via coughing, sneezing or simply talking. Treatment:

First line: Isoniazid

Second line: Streptomycin

Diagnosis
Exposure?

Tuberculin Skin Test

Chest X-ray

Acid-fast stain and culture

Link with HIV

Risk of progression to disease (from infection) is higher. Miliary TB (more disseminated) is more common amongst HIV sufferers. TB may in fact accelerate the onset of AIDs via TNF-alpha which induces viral transcription and/or activation of CD4+ T cells that support viral replication. Symptoms of TB may be the presenting manifestation in early AIDS sufferers.

Human Immunodeficiency Virus (HIV)

Transmission: Blood Semen Vaginal secretion Breast milk Situations: Unprotected sex Direct blood contact (needles) Mother to baby

HIV: Structure

HIV: Replication
1. BINDING 2. ENTRY 3. REVERSE TRANSCRIPTION 4. INTEGRATION 5. TRANSCRIPTION AND TRANSLATION 6. RELEASE

RESPONSE OF THE IMMUNE SYSTEM

Class I MHC molecules present the viral epitopes on infected cells that activates the cytotoxic imune response. Release of interleukins Multiple mutations confuse the immune system

HIV DIAGNOSIS
PERSISTENT GENERALIZED LYMPHADENOPATHY (>3months ) involvement of atypically located lymph nodes T helpers cell count <400per microlitre ELISA test HIV specific serum antibodies

Western Blott/immunofluorescence test

Sources/References
http://bestpractice.bmj.com/best-practice/monograph/555/diagnosis/differential.html http://www.aafp.org/afp/1998/1015/p1313.html http://www.merckmanuals.com/professional/infectious_diseases/mycobacteria/tuberculosis_tb.html#v1010744 http://www.aids.org/topics/aids-faqs/how-is-hiv-transmitted/ http://highered.mcgraw-hill.com/sites/0072495855/student_view0/chapter24/animation__hiv_replication.html http://amath.colorado.edu/cmsms/index.php?page=hiv-early-infection-pathogenesis-modeling http://emedicine.medscape.com/article/229461-clinical http://emedicine.medscape.com/article/229461-clinical#a0256 http://emedicine.medscape.com/article/229461-workup http://www.altiusdirectory.com/Health/vdrl-test.php

http://www.umm.edu/ency/article/003533.htm
http://publichealthlab.ca/reportingname/rpr-rapid-plasma-reagin/ http://www.medterms.com/script/main/art.asp?articlekey=9845 Robbins Basic Pathology, Saunders,8th Edition Kumar, Abbas Fausto, Mitchell, page 700-702

Colour Atlas of Immunology, Thieme, Gerd-Rdiger Burmester, Antonio Pezzutto, Timo Ulrichs, Alexandra Aicher, Pages 124126
Essential Clinical Immunology by John B. Zabriskie p.231-250.