HIV signs and symptoms: Page 1476 of Harrison’s IM

PTB s/s: Page 1290

Differential diagnoses and bases of each. Other possible diagnosis for the patient’s case aside
from Acute HIV Syndrome are Pulmonary Tuberculosis and COVID-19 pneumonia.

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The patient presented with respiratory complaints such as severe dyspnea, shortness of breath, 2
weeks productive cough, fever, and lung crackles with wheezing. These respiratory complaints
can be seen on all the differentials as pulmonary disease is one of the most frequent
complications of HIV infection, manifesting as pneumonia or a flu like illness with fever.

There is also the possibility of PTB due to the productive cough lasting for 2 weeks and fever.

COVID-19 pneumonia must also be considered as respiratory symptoms are present. These signs
and symptoms may appear 2 days to 2 weeks post viral exposure. (Lung crackles may be present
as a result of infection and may be assessed through chest radiography. In COVID-19 disease,
there is usually diffuse or patchy opacities that may indicate viral or bacterial pneumonia.)

*essential tests to differentiate

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The patient’s past medical history indicates that he was previously managed as a case of
extensive PTB 1 month prior and was started on anti-koch’s treatment. In acute HIV infection,
there may be a coexisting pulmonary tuberculosis infection due to a defect in cell mediated
immunity. Active TB often develops relatively early in the course of HIV infection and may be
an early clinical sign of HIV disease.

This past medical history also proves that the patient was indeed diagnosed and was treated with
anti-TB medications. The patient in this case is still within his first month of anti-TB treatment.
During the first 2 months of treatment, which is the intensive phase of standard TB regimen, is
when the bactericidal process happens, in which majority of the tubercle bacilli are killed,
symptoms are resolved, and the patient is noninfectious anymore. The patient still has not
completed the intensive phase yet hence, signs and symptoms of coughing may still persist. But,
exacerbation of the respiratory signs and symptoms to the point of severe dyspnea and shortness
of breath must warrant the physician to assess the patient’s compliance to the treatment regimen
or to assess coexistence of other possible medical conditions that warrant prompt management.

For the COVID-19 pneumonia, cough and dyspnea are common respiratory complaints but the
longest time between viral exposure to symptom onset is 14 days only.

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Having a large number of sexual partners poses a risk for possible exposure to HIV infection.
Whereas, this risk factor does not directly cause PTB and COVID-19 infection.

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Generalized weakness, loss of appetite, diarrhea, dysphagia and weight loss are present in all of
the mentioned disease conditions.

Infections of the small and large intestine leading to diarrhea, abdominal pain, and occasionally
fever are among the most significant GI problems in HIV-infected patients. This is due to the
infections with bacteria, protozoa, and viruses. Infection of the GI tract are more common in men
who have sex with men. Patients with untreated HIV have approximately a 20-fold increased risk
of infection to which they may present with a variety of nonspecific symptoms including fever,
anorexia, fatigue, and malaise of several weeks’ duration.

For TB, although gastrointestinal TB is uncommon, this must also be considered as the patient
already presents with abdominal pain, fever, weight loss, and anorexia.

GI signs and symptoms are also present with the COVID-19 disease. Cheung and colleagues
conducted a systematic review and meta-analysis to evaluate the occurrence of gastrointestinal
(GI) symptoms (anorexia, nausea, vomiting, diarrhea, abdominal pain or discomfort) in patients
with COVID-19 and they found out that 17.6% of patients with COVID-19 had GI symptoms.
Stool tested positive for SARS-CoV-2 RNA in 48.1%, including stool collected even after
respiratory samples tested negative for viral RNA.

*systemic effect of diarrhea: anorexia

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Palpitations and tachycardia may be seen as a direct consequence of HIV infection, PTB, or
COVID-19 infection. Heart disease is a relatively common postmortem finding in HIV-infected
patients (with 25–75% in autopsy series). Patients with HIV infection have higher levels of
triglycerides, lower levels of high-density lipoprotein cholesterol that may predispose the patient
to cardiovascular diseases. The patient also has a family history of cardiovascular disease on his
maternal side.

A variety of cardiovascular problems are found in patients with HIV infection. Pericardial
effusions may be seen in the setting of advanced HIV infection. Predisposing factors include TB,
CHF, mycobacterial infection, and pulmonary infection. If other signs such as dull retrosternal
pain, and pericardial friction rub are present, pericardial TB or tuberculous pericarditis may also
be considered.

There is also cardiac injury as a complication of COVID-19 disease. Multiple case series have
noted that there is an increased burden of cardiovascular disease (4-14%) and cardiovascular
comorbidities in patients with COVID-19, often associated with increased morbidity and
mortality. The risk for cardiac injury is evidenced by increased troponin levels. The
pathophysiology of injury is still under investigation, but some presentations seem related to
cytokine storm. In which the cardiac injury may be due directly to cytokine-induced tissue
damage or may result from immune-cell–mediated responses.

Lastly, oral thrush on the tongue and soft palate may be a sign of a mild oral candidiasis which is
common in people with untreated HIV infection but not with PTB and COVID-19 disease.

2. Explain the bases for each of your differentials.

Patient’s Data Acute HIV Pulmonary COVID-19

syndrome Tuberculosis  Pneumonia

Respiratory
complaints: (+)  (+)  (+)
 Severe dyspnea
and shortness of Pulmonary disease All persons with Common signs and
breath is one of the most productive cough symptoms of
 2 weeks frequent lasting for 2-3 weeks COVID-19 are
productive complications of or more should be cough, dyspnea,
cough with HIV evaluated for TB. fever, and shortness
fever infection. The most There is also a of breath that may
 Mid-bibasal common presence of fever, appear 2 days to 2
crackles. manifestation of usually diurnal, in TB. weeks after viral
Occasional pulmonary disease exposure.
wheezing is
Pneumonia. Lung crackles may
be present as a result
HIV may present as of infection and may
a flu like illness be assessed through
with fever. chest radiography. In
COVID-19 disease,
there is usually
diffuse or patchy
opacities that may
indicate viral or
bacterial pneumonia.

PMH:
 Cough and (+)  (+) (+) 
dyspnea
(managed as a There may be a Signs and symptoms
 case of coexisting experienced by the
extensive PTB) pulmonary patient may be due to
 Started on anti- tuberculosis poor adherence to
koch’s infection associated treatment and must be
treatment with a defect in cell properly evaluated and
mediated immunity. educated by the
physician. 
Active TB often
develops relatively There may also be
early in the course existence of
of HIV concomitant medical
infection and may conditions that caused
be an early clinical exacerbations of
sign of HIV disease respiratory signs and
symptoms despite
ongoing treatment and
must be addressed
accordingly.

Multiple sexual (+) (-) (-)

partners: 3 females and
4 males A large number of
sexual partners
poses a risk for
possible exposure
to HIV infection

Weight loss of 28 kg (+) (+) (+)

(span of 1 year),
weakness, scaphoid Anorexia, weight Weight loss, anorexia, General weakness,
abdomen, anorexia, loss, possible general malaise, loss of appetite,
dysphagia, and diarrhea pharyngitis, diarrhea, dysphagia dysphagia are
diarrhea and and weakness may present in COVID-
generalized also be present 19 disease and these
weakness are often especially if there is can affect food
present already intake. Diarrhea can
gastrointestinal TB also happen. All of
these may lead to
loss of lean mass or
body weight.
Palpitations, (+) (-) (-)
tachycardia (HR: 118 This may be a
bpm). History of CVD direct consequence
in the maternal side. of HIV infection or
associated with
classical risk
factors  such as
alcoholic beverage
drinking

Oral thrush on tongue (+) (-) (-)

and soft palate
Mild oral
candidiasis is
common in people
with HIV infection