Case report: late diagnosis of HIV at clinical stage 4 with pulmonary and CNS tuberculosis

Abstract

On admission, the healthcare client reported a three-week history of headache, periodic seizures without loss of consciousness, fever up to 38.4°C, and weakness in the left arm. A previously performed contrast-enhanced brain CT scan revealed abscesses in the temporal lobe (Fig.1). He did not deny alcohol abuse. Physical examination revealed mild neck stiffness, diminished breath sounds in the lower lung zones (predominantly left), and ascites. A rapid HIV test returned positive. HIV viral load in blood was 112,000 copies/mL; in CSF – >10,000,000 copies/mL; CD4 cell count – 170 cells/μL. Markers for hepatitis B and C were negative. Initial cerebrospinal fluid (CSF) analysis showed mild pleocytosis (87 cells/μL, 52% lymphocytes), elevated protein (2.14 mmol/L), and normal glucose (2.6 mmol/L). Chest X-ray revealed signs of lower lobe pleuropneumonia on the left and likely disseminated tuberculosis on the right (Fig.2). GeneXpert testing of CSF and sputum was positive for M. tuberculosis, with no rifampicin resistance. PCR testing of CSF for herpesviruses and T. gondii, along with a rapid cryptococcal antigen test, returned negative results. The healthcare client was started on anti-tuberculosis therapy (HRZE regimen), ART (DTG/3TC/TDF), and prophylactic TMP-SMX. He was discharged with clinical improvement after three weeks for outpatient follow-up and continuation of therapy.