5-78
Objective: Signs
Using Basic Tools: Inspection: Acute (1-30 days): Fever to 102°F, aphthous oral ulcers, maculopapular rash
on neck and trunk. Sub-acute (30 days-1 year): Generalized adenopathy. Chronic (> 1 year): Fevers as high
as 104°F, cachexia, oral thrush, Herpes zoster, signs of opportunistic infection (see Table 5-75)
Palpation: Sub-acute (30 days-1 year): Generalized adenopathy
Using Advanced Tools: Lab: Blood smear for lymphopenia and atypical lymphocytes.
Assessment:
Differential Diagnosis (in addition to AIDS and HIV-related illnesses)
Generalized TB - HIV patients are often co-infected with TB (see ID: TB), and may have chest X-ray findings.
Disseminated histoplasmosis - febrile wasting illness, unlikely to have oral thrush or shingles
Visceral leishmaniasis - chronic wasting, febrile illness with prominent hepatosplenomegaly (unusual for HIV
alone), pancytopenia; history of travel to endemic area
Lymphoma - may present in a disseminated form like HIV symptoms; pronounced lymphadenopathy, spleno-
megaly
Acute viral illness - CMV, mononucleosis, hepatitis B, and adenovirus (see topics)
Plan:
Treatment
There is no cure. Evacuate newly diagnosed team member with HIV with an escort (suicide watch). Safeguard
his weapon. Do not attempt to institute treatment, unless evacuation not available in the foreseeable future.
Then test with PPD and treat with INH prophylaxis if >5mm (see ID: TB). Also treat active opportunistic
infections (see appropriate topic). Refer local nationals to host nation medical resources.
Patient Education
General: Discourage pregnancy due to significant risk of sexual transmission to the partner, perinatal
transmission to the fetus, and the likelihood that the mother will not survive to raise the child.
Diet: Maintain nourishment (AIDS patients are often severely malnourished). Replace vitamins. Note frequent
lactose intolerance.
Prevention: Use latex condoms for sexual intercourse. Do not have unprotected sex, re-use needles, or be
careless with body fluids. Do not breastfeed baby if formula is available, safe, cheap, and not dependent on
unsafe water supply. Avoid contact with ill persons to avoid contracting diseases.
NOTES: Medics should use body fluid precautions: latex gloves and gown to handle fluids; add eye protection
and mask for potential contact with blood and body fluids under pressure (needle stick, dental work, etc.).
Wash skin well with soap and water if it becomes contaminated with body fluids.
Occupational needlestick/post exposure prophylaxis:
Zidovudine/lamivudine (Combivir) one pill bid and efavirenz 600mg po q hs
or nevirapine 200 mg po qd for 2 weeks
then 200 mg bid
or Protease inhibitor (nelfinavir 1250 bid,
indinavir 800 mg tid)
Retroviral must be started ASAP for maximal protection and continued for four weeks after needlestick/
exposure.
ID: Infectious Mononucleosis
LTC Niranjan Kanesa-thasan, MC, USA and COL Warren Whitlock, MC, USAIntroduction: Infectious mononucleosis (IM) is caused by one of the most common human viruses, the
Epstein-Barr virus (EBV), a member of the herpes virus family. In the developed world, “mono” is particularly