A 21-Year-Old Woman With Persistent Fever and Malaise

Muralikrishna Gopalakrishnamoorthy, MBBS, PGY-1; Archana Bhaskaran, MBBS, PGY-1; Rajeswari Anaparthy, MBBS, PGY-1; Ted T. Lin, MS3; Syed Hasan, MBBS

Disclosures

September 30, 2015

Physical Examination and Workup

On physical examination, the patient is noted to be tachycardic, with a heart rate of 105 beats/min. She is febrile, with a temperature of 103.3°F; in addition, she has mild tachypnea, with a respiratory rate of 26 breaths/min, and she is noted to have a moderately increased respiratory effort.

The patient appears cachectic and fatigued, but she is easily arousable. She is not disoriented and has normal speech and comprehension.

Inspiratory and expiratory crackles are heard in the anterior right lung field. No cardiac murmurs or gallops are present. The jugular veins are not elevated. No peripheral edema or lymphadenopathy is appreciated. Her abdomen is soft, nontender, and without palpable masses. No rashes or skin lesions are detected.

Figure 1.

Figure 2.

The remainder of the examination is unremarkable. Diagnostic laboratory studies reveal a white blood cell count of 5 × 103 cells/µL, a hematocrit of 22.5%, a hemoglobin value of 8 g/dL, a mean corpuscular volume of 69.7 fL, and a platelet count of 219 × 103 cells/µL. The CD4 count at presentation was 9 cells/ µL(normal range, 522-1594 cells/ µL), with an HIV branched DNA viral load > 500,000 copies/mL.

Electrolyte measurements are normal except for a bicarbonate level of 18 mEq/L. Liver function test results are abnormally elevated, with an alkaline phosphatase value of 301 U/L, an aspartate aminotransferase values of 56 U/L, and an alanine aminotransferase value of 490 U/L. The lactate dehydrogenase (LDH) level is also elevated, at 6450 U/L.

Arterial blood gas analysis showed the following values:

  • pH: 7.46

  • pCO2: 29

  • pO2: 154

  • HCO3: 19

Chest radiography (Figure 1) and subsequent CT of the chest (Figure 2) are obtained.

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