CLINICO-PATHOLOGIC CONFERENCE OUTPUT

Leader: Cadua, Norman Vryne

Members:
 Arriola, Charls Davhram Balomaga  Mangaban, Joelle Denise Aniciete
 Camacho, Anton Miguel Esporlas  Miranda, Samantha Louise Javier
 De Leon, Rhemielene Lentija  Pastor, Reine Christine
 De San Agustin, Jessy Mae Legaspi  Roxas, Bianca Abay
 Laton, Alvina Patricia Loyloy   Tiu, Kenn Janzen Escobar 
 Macawadib, Amerah Tul Kusna Ayo  Villaseñor, Nigelle Pakingan
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Primary Diagnosis: HIV
The primary diagnosis of HIV in our patient is based on the clinical impression of non-
specific symptoms of on-and-off fever, body malaise, multiple erythematous rashes, recurring
diarrhea lasting for 3-7 days every two months for the past two years, and supraclavicular
lymphadenopathy on PE which coincides with the clinical presentation of acute retroviral
syndrome. However, during the hospital stay of the patient, there was a progression in the size
of the skin lesions with associated edema in his lower extremities,  sore throat, and multiple
white lesions on his oral mucosa which may be due to secondary neoplasms, and opportunistic
infections as the major target of HIV infection is the immune system, and profound immune
deficiency is the hallmark of AIDS. This leads to impairment of other functioning immune cells
and eventually to infections.
The primary diagnosis is supported by the rashes presented by the patient which were
initially described as multiple erythematous rashes on his back and chest area with occasional
pruritus. Then, these lesions became purplish-red and had spread to his lower extremities, one
week later. Along with these rashes, undocumented fever and body malaise were also
observed. These characteristics match the generalized rash that is commonly presented by
symptomatic acute HIV infected individuals, which is described as small, well-circumscribed,
oval or round, pink to deeply red colored macules or maculo-papules that manifests on the
upper thorax, collar region, face, scalp, and extremities. Although the initial manifestation of the
patient’s lesions matches the acute and early rashes of HIV, their progression to a larger size
with concomitant edema on the lower extremities on the fourth day of hospitalization coincides
with the inflammatory cytokine syndrome brought by Kaposi Sarcoma. This syndrome presents
as fever, edema, neuropathy, gastrointestinal and respiratory symptoms which may be due to
elevated C-reactive protein as presented by the patient. Since, Kaposi Sarcoma is one of the
AIDS-defining illnesses, it is highly likely that the patient’s diagnosis is suggestive of AIDS.
The patient also presented with persistent productive cough, fever, occasional dyspnea, 
tachypnea, and crackles on bibasal lung fields upon physical examination. On chest radiograph,
bilateral interstitial infiltrates at the perihilar region were observed, characteristic of a
pneumocystis infection. Approximately 15% to 30% of people who have weakened immune
systems such as HIV-infected people develop pneumonia caused by the fungus Pneumocystis
jirovecii during the course of the disease. Symptoms presented by the patient, chest radiograph
and negative sputum culture suggest pneumocystis pneumonia. 
The patient’s history of watery diarrhea lasting for 3-7 days every two months for the
past 2 years can be interpreted as HIV-associated enteropathy. Diarrhea is common in adults
with HIV, approximately 40 percent of patients reported at least one episode of diarrhea in the
preceding month. HIV also directly invades various intestinal cell populations and disturbs gut
motility by affecting the autonomic nervous system leading to enteropathy. 
White lesions in his buccal mucosa may indicate oral candidiasis, which when viewed
along with the myriad of signs and symptoms indicating immune deficiency, points to a primary
diagnosis of HIV. Multiple studies reported oral candidiasis to be the most prevalent
opportunistic fungal infection found in HIV-positive patients. It afflicts HIV patients more than
those with a similar degree of immunosuppression, for example, those undergoing bone marrow
transplants or patients receiving chemotherapy. This colonization is possible since HIV causes
adaptive immunity disruption by decreasing the body’s CD4+ T cells, which in turn affects the
function of innate effector cells such as neutrophils and macrophages. The resulting deficiency
in immune cell function causes opportunistic microorganisms to thrive.
Upon the history of the patient, he previously worked as a call-center agent for 5 years,
putting him under the high index of suspicion for contracting venereal diseases and HIV, as
expressed in the study conducted in 2010 by the University of the Philippines and DOH, that
more call-center agents have early penetrative premarital sex and have had sex with the same
sex. It was revealed that nearly one-third of male call center agents had casual sex,  regardless
of gender, and they tend to be involved in risky behaviors due to their environment and peer
pressure. 
Based on the clinical manifestations, the patient is in the symptomatic stage of HIV
infection. Constitutional symptoms already manifested in the patient’s condition such as Kaposi
sarcoma, oral candidiasis, and pneumocystis pneumonia secondary to opportunistic infections.
Clinical staging must be determined in the patient to determine diagnosis, evaluation, and
management of the disease based on clinical findings in the absence of CD4 cell count. Since
the patient already presents with pneumocystis pneumonia and Kaposi sarcoma, we can
presume that the patient is in clinical stage 4 of illness based on his clinical presentation.

Differential Diagnoses
1. Chickenpox
Chickenpox is a highly infectious illness spread by droplet infection from the upper
respiratory tract. One month prior to consultation, the patient was exposed to her sister
with chickenpox who lives with him which is in the incubation period of the virus before
the onset of rash. Pruritic maculopapular rashes in the back and trunk, fever, and
malaise before the onset of rash are all suggestive of chickenpox. Bilateral infiltrates are
also suggestive of varicella pneumonia if the patient is immunocompromised. However,
the pattern of distribution of the rashes is different. Common sites of erythematous
macules of chickenpox are on the face, scalp, trunk, and proximal limbs rapidly progress
to papules, vesicles, pustules, and crusting. It usually begins in the face and scalps and
spreads rapidly to the trunk, with relative sparing of the extremities which are different
from the patient’s rash starting from the chest and back and appearing in the lower
extremities also. The usual size of the rashes differs also.
2. Atopic Dermatitis
Atopic dermatitis manifests with a defective skin barrier, reduced innate immune
responses and exaggerated immune responses to allergens and microbes.  Both genetic
predisposition and environmental factors play a role in the development of atopic
dermatitis. Based on the patient’s clinical presentation, a possible diagnosis of atopic
dermatitis was made. This was considered as a close differential diagnosis and was
ruled in because of the presence of pruritus and rash, which are the major features of
atopic dermatitis in which the patient both manifested. Aside from the erythematous rash
which was noted to be itchy, the patient also has asthma which has a known predilection
to atopic dermatitis. Patient’s laboratory results presented with high eosinophils similar to
a patient with atopic dermatitis. Some studies show that high CRP might speculate that it
could also contribute to AD comorbid conditions. Cetirizine was also used to relieve
pruritus, an effective treatment for similar cases of atopic dermatitis. However, it was
ruled out because of its pattern of distribution of rashes. The patient’s rash started in the
back and chest that travels to his lower extremities. In atopic dermatitis, the distribution
of erythematous scaly papules in adults is on the localized flexural extremities,
specifically on the antecubital fossa and popliteal fossa, hands, dorsum, and feet. The
rash in atopic dermatitis is also characterized to be scaly which is not found in the
patient's clinical presentation. No other associated findings strongly suggestive of atopic
dermatitis was found such as allergic shiners, dennie morgan fold, pityriasis alba, and
keratosis pilaris was found thus, the diagnosis of atopic dermatitis was ruled out.
3. Erythema Multiforme secondary to Infectious Mononucleosis  by EBV
EBV can be transmitted through saliva which can be attributed to the patient's history of
liking street foods. Its infection manifests as IM that initially presents as fever and
malaise which further develops into generalized maculopapular rashes with oral lesions.
Together with it and the patient’s history of pneumonia coincides with the possible
development of EM since both factors are known to trigger it. It also supports the
progression of lesions seen in the patient, as it initially appeared as multiple
erythematous rashes that then progressed in size. Furthermore, based on epidemiology,
EM most frequently occurs in young male adults. However, it can be ruled out since EM
lesions commonly present as distinct targetoid lesions which are impossible to miss out.
Also, the distribution of lesions are initially found in the distal extremities, specifically the
back of the hands and feet and spreads proximally. Atypical lymphocytosis should also
be present. In infectious mononucleosis, liver transaminases are typically elevated which
are normal in the patient.
4. Secondary Syphilis
Secondary syphilis represents overt systemic dissemination. It is overt because during
primary syphilis there is covered systemic dissemination, treponemes disseminate early
but undetected until the immune response begins. The patient’s PE showed
lymphadenopathy and maculopapular rashes in his trunk and lower extremities. He also
had fever and malaise which are suggestive of the disease. However, the pattern of
distribution of the maculopapular rashes of the patient is different. In secondary syphilis
with patients having a widespread rash (generally on the face, scalp, palms of hands,
and soles of the feet) with generalized lymphadenopathy and lesions can range from 1–
2 mm to 15–20 mm in diameter, and they vary in color from pink to violaceous to red–
brown which are different from the patient’s findings. Also, there is no history of chancre
in the genitalia of the patient which is the first and primary sign of syphilis infection.
Other lesions include condyloma lata which are moist flat, raised lesions usually seen
around the anus and on mucous patches in the mouth and on the tongue are also
absent. Common systemic symptoms that were lacking include anorexia, headache,
arthralgia, and generalized lymphadenopathy.