Journal of the New Zealand Medical Association, 18-June-2004, Vol 117 No 1196
Don’t forget about HIV
The incidence of human immunodeficiency virus (HIV) infection is rising in New Zealand. In 2003, there were 154 new diagnoses of HIV infection in New Zealand, more than in any previous year, and less than half of these were amongst men who have sex with men.1
The following cases are presented briefly to encourage health practitioners to think of the possibility of HIV infection and to test for it when appropriate.
A 33-year-old man, who had come to New Zealand from Kampuchea (formerly known as Cambodia) in 1997, presented to his general practitioner (GP) with chronic cough and weight loss. He was anaemic (Hb=126g/L) and lymphopaenic (0.83x109/L); and had a polyclonal hypergammaglobulinaemia (IgG=28.8g/L). He failed to respond to sequential treatment with doxycycline for 10 days, erythromycin for 7 days, and roxithromycin for 14 days. He was referred to the respiratory medicine clinic of a large metropolitan hospital where further investigation showed right upper lobe and lingular infiltrates, normal bronchoscopic appearances, no evidence of infection with routine respiratory pathogens or Mycobacterium tuberculosis, and no evidence of malignancy.
At follow-up, his weight (which had been 96kg at the onset of his illness) had fallen to 68 kg. Two weeks later, he attended another general practitioner complaining of a cough, which had disturbed his sleep for the previous 6 months. He was tachypnoeic (30/min) but had no other abnormal findings on respiratory examination. He was discharged home where he was found dead by his family the next day. A coroner’s post mortem examination demonstrated Pneumocystis jiroveci (previously P. carinii) pneumonia and cytomegalovirus infection of the adrenal glands. An HIV-antibody test was positive.
This man died as a result of the acquired immune deficiency syndrome (AIDS), which was not recognised despite contact with his GP and a hospital service. Any progressive, unexplained illness in an otherwise healthy person should arouse suspicion of HIV infection, especially when that person has emigrated to New Zealand from an area of the world with high endemic rates of HIV infection.
A 2-year-old Polynesian boy had been investigated since birth for seizure disorder and developmental delay. An HIV test was recommended, but was not performed until 6 weeks after the birth of a younger sibling. Both children and their mother were found to have HIV infection, and the father was HIV-antibody negative. The younger child became unwell with pneumocystis and cytomegalovirus pneumonia. It is likely that the mother was infected with HIV several years ago via heterosexual intercourse with a man from Papua New Guinea.
The offer of routine HIV testing to all pregnant women in New Zealand remains contentious. Early diagnosis of HIV infection in this woman would almost certainly have prevented transmission of perinatal HIV infection. Five children are known to have acquired perinatal infection in New Zealand during 2003.1 Most of these infections could have been prevented if the mother’s HIV infection had been recognised.
HIV infects people from all walks of life at all ages. The overall prevalence of HIV infection in adults aged 15–49 years is approximately 8% in sub-Saharan Africa, and 1% in Thailand, Kampuchea, and Vietnam.2 In Port Moresby (Papua New Guinea), the prevalence of HIV infection among pregnant woman attending antenatal clinic is estimated to be 1%.2
In the cases above, recognition of sexual intercourse with a person from a high prevalence country should have raised concerns about the possibility of HIV infection. Earlier diagnosis has the potential for huge benefit—by preventing perinatal infection, and by provision of treatment to prevent life-threatening illnesses due to immune-deficiency.
Dr Stephen Ritchie, Ms Vanessa Cramond, Associate Professor Mark Thomas
Infectious Diseases Unit
Auckland City Hospital
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