1. Put the preliminary diagnosis.

2. What is the peculiarity of the case of manifest?

Answer

1. The patient, administered intravenously psychotropic drugs, there is a staphylococcal sepsis and probably bacterial endocarditis. Related diagnosed with HIV infection, stage III.

2. This condition is not associated with the progression of HIV infection, due to the development of staphylococcal infections acquired as a result of the use of non-sterile instruments (needle or syringe) solution or contaminated drugs. The patient seems to be infected with HIV recently (uses drugs for 3 years, no severe immunodeficiency - the number of lymphocytes Cn 0.52 * 109 / L).

Task 7

The patient, 39 years old, physical education teacher, a member of the dispensary Registered in the town center for prevention and control of AIDS seven years. Over the past year suffered a PCP and two recurrent herpetic infection (herpes zoster). Two months ago, it was the sense of vat increasing weakness in the legs, and then joined the pain and numbness in the feet and legs, was the body temperature to rise to 38 ° C, no appetite, have stomach pain, occasionally diarrhea mixed with blood and mucus 3- 4 times a day. Especially worried blurred vision - blurred contours of objects and flashing "flies" in front of the right eye.

On examination: emaciated, pale. On palpation abdominal pain in the lower divisions. The liver is below the costal arch to 2 cm. Decreased tone and wasting of muscles of the lower limbs, disturbance of sensitive-sti. Neurologist revealed Polyradiculopathy. Examined by an eye doctor, diagnosed with necrotizing retinitis right eye, hemorrhagic vasculitis left. Due to the presence of intestinal dysfunction, detecting blood in stool done endoscopy intestine to identify county-erosive and ulcerative Proctosigmoiditis. Spend a biopsy of the intestinal mucosa.

1. About the development of some opportunistic infections can be thought of? Formulate a diagnosis.

2.Dostatochno whether conducted studies to confirm the diagnosis? What additional research is needed?

3.put treatment plan.

Answer

1. When Polyradiculopathy and visual impairment (necrotizing retinitis) should first of all think about the manifestation of cytomegalovirus infection. In favor of CMV infection suggest clinical data (retinal necrosis, bilateral its defeat Polyradiculopathy, erosive and ulcerative Proctosigmoiditis Diagnosis:. HIV infection, stage of secondary manifestations (1UV) in the progression phase of CMV infection (retinitis, Polyradiculopathy, erosive and ulcerative Proctosigmoiditis).

2. Confirm the diagnosis is necessary by the PCR method to detect CMV DNA in blood and biopsy of the intestinal mucosa (not only qualitative but also quantitative method) to confirm the symptomatic form of the disease.

3. The patient should be assigned along with HAART ganciclovir (Cymevene *) at a dose of 5 mg / kg body weight per day, intravenously for at least 14 days (up to 21) depending on the dynamics of clinical manifestations. In the future - the transition to maintenance therapy.

Task 8

The neurological department of the hospital caused by the ambulance to the 32-year-old patient. Status heavy, mind confused, pale, cyanosis of nasolabial triangle, the body temperature of 38 ° C, occasionally observed vomiting, cramps. According to relatives, sick for a long time - about a month ago began to complain of periodically growing headache, weakness; 2 weeks ago began to increase body temperature up to 37,5-38 ° C, appeared unsteady gait, dizziness. He stopped going to work. A week ago there were auditory hallucinations, in the last days - vomiting.

The patient had consulted a neurologist district, which revealed the presence of focal symptoms and recommended urgent hospitilization. The office on the background of pathogenetic therapy condition continued to deteriorate. When carrying out a computer tomography of the brain detected round seal center in the cortex of the right hemisphere, surrounded by edematous tissue. It received positive blood tests for antibodies to HIV (blood taken when entering the office). Ambulance patient was taken to the office for patients with HIV infection. In the study of immune status showed a reduction in the number of lymphocytes C04 - 0.06 x 109 / l.

1. Put the preliminary diagnosis. What is necessary to exclude secondary disease in the first place?

2. Formulate a clinical diagnosis.

3. What studies should be conducted to confirm the diagnosis?

4. Determine the treatment policy.

Answer

1. A gradual increase in clinical symptoms (headache, fever, hallucinations, impaired consciousness, the presence of focal neurological symptoms), the discovery of the seal chamber in the brain revealed during CT in patients with HIV infection with a reduction in the number of lymphocytes to C04 0,06h109 / l primarily requires the exclusion of cerebral toxoplasmosis. Differentiate with lymphoma of the brain, fungal abscess.

2. HIV infection, stage of secondary manifestations 1UV (AIDS) in the progression phase: cerebral toxoplasmosis.

3. Effective laboratory techniques do not currently exist.

4. First of all it is necessary to achieve clinical improvement: You should begin treatment of toxoplasmosis (sulfadoxine + pyrimethamine (Fansidar *), pathogenetic treatment), which is held for a long time (improvement does not take place 2-4 weeks before the beginning of therapy) - a few weeks or even months under the control of computer tomography (resorption of the hearth). Later switching to maintenance therapy with the inclusion of ART.

Task 9

The patient, 40 years old, does not work, is registered in the center of the prevention and control of AIDS within a year of his sentence in prison. Diagnosis at statement on the account: HIV infection, 1UB stage (body weight loss of about 10%, frequent exacerbations of chronic bronchitis, recurrent pharyngitis, recurrent herpetic lesions on the lips, oropharynx mucosal candidiasis). Over the past 3 months I lost 10 kg. Naroslo weakness appeared sweating at night, increased body temperature up to 37,5-38 ° C, occasionally worried cough with viscous sputum, shortness of breath while climbing the stairs. It was treated with folk remedies. The state of health has deteriorated, he turned to the doctor and center of prevention of AIDS.

On examination: body temperature 38 ° C, emaciated, pale and rigid in the lungs breathing, scattered dry rales, respiratory rate 26 per minute, heart sounds are muffled, pulse 90 per minute. The liver is below the edge of the costal arch to 2 cm. X-ray examination of the lower parts of the lungs revealed foci of rounded outlines of irregular shape. When ultrasound of the abdomen

found enlarged liver with diffuse parenchymal changes. In the course of hepatic-duodenal ligament and at the gates of the spleen enlarged Lim-phatic nodes (10-13 mm).

1. What symptoms may indicate a new patient?

2. Diagnose.

3. Schedule a treatment plan.

Answer

1. Fever, weakness, weight loss, night sweats, cough with viscous sputum, and the X-ray pattern of light and ultrasound data (liver disease, intra-abdominal lymph nodes), data epidemiological history (staying in prison) may indicate a generalized tuberculous process.

2. HIV-infected patients in 1UV stage (AIDS) in the progression phase, generalized tuberculosis.

3. Tactics of treatment is determined by the severity and form of the disease in conjunction with the TB specialist.

TASK 10

The patient, 23 years old, is registered in the center of the prevention and control of AIDS in the period of 2 years with a diagnosis of "HIV, the stage of secondary diseases (MBG) (weight loss, recurrent pharyngitis, candidiasis oral mucosa)." Over the past 4 months I have lost 10 kg. Naroslo weakness during the passage of food through the esophagus. To the doctor did not address, I was treated independently (analgesics reception). The state of health has deteriorated.

When viewed at the center of prevention and control of AIDS revealed a significant depletion pallor. In the mouth - a massive loose overlay on the mucous membrane of the hard palate and posterior pharyngeal wall. On the part of other organs revealed no pathology. At esophagogastroduodenoscopy in the esophagus found many white patches, sometimes merging and elevated above the mucous membrane on the background of hyperemia and edema.

1. What are the new manifestations of secondary diseases are a patient? What do they show?

2. Schedule a treatment plan.

Answer

1. New evidence of infection in a patient signs of widespread candidiasis: the defeat of the mucous membrane of the mouth and throat, Candida esophagitis, which suggests a feeling of a lump in the chest, pain in the course of the esophagus while taking food, the changes detected by esophagogastroduodenoscopy. Development candida esophagitis can talk about the progression of the disease and the transition of HIV infection in 1UV stage.

2. Assign the ARV (eg nelfinavir - protease inhibitor, AZT and ddI - nucleotide reverse transcriptase inhibitors) and to treat candidiasis fluconazole (Diflucan *).

Task 11

The patient, 28 years old, a miner. I arrived in Moscow from Donetsk for a consultation about a constant diarrhea that does not respond to treatment (within the last 3 months have been tried various medications, including furazolidone, cotrimoxazole (Biseptol *), metronidazole (Trichopolum *) entegnin *, enzyme preparations, some antibiotics ,anthelmintics, etc.). Loose stools initially bothered by 2-3 times a day, then quickened up to 12-17 times. Grown thin for this time for 18 kg. Notes extreme weakness. At the train station was a short-term loss of consciousness. Brigade ambulance rushed to hospital with suspected food poisoning, cholera.

In the department during the day a marked, almost constant diarrhea, copious stools, watery, lost fecal character, evil-smelling. Objectively: pale skin turgor is reduced, on the scalp and back phenomenon seborrhea; angular cheilitis. Pulse 96 per minute, blood pressure 80/60 mm Hg Language dryish, coated. Palpation of the abdomen is painless.

Urination is not broken. Around the anus genital warts. No meningeal phenomena. Bacteriological study of feces of any pathogens were found. Antibodies to HIV by ELISA and immune blotting.

1. Put the preliminary diagnosis. What kind of opportunistic infection, you can think of?

2. How to confirm your guess?

Answer

1 in patients with HIV infection is likely to stage a GID. Diarrhea for a long time, weight loss, mucous membranes and skin show advanced immunodeficiency and suggest cryptosporidiosis.

2. To confirm the diagnosis of cryptosporidiosis should conduct bacterial analysis of faeces for the detection of Cryptosporidium oocysts.

3. There is no evidence of the presence of cholera, there is, despite the presence of watery diarrhea, and some signs of dehydration. Duration of diarrhea, fever, lack of typical epidemiological history, negative stool crops allow to reject the diagnosis of cholera.

4. The patient must assign ART that may lead to an improvement of immunity (increased number of lymphocytes C04) and the onset of clinical recovery from cryptosporidiosis. At the same time should be the pathogenetic and symptomatic therapy (diet, intravenous saline solutions, parenteral nutrition, enzymes and so forth.).

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