COTW: HIV and lung disease

(from Eric)

We have a 40 year old Maasai lady on the female medical ward currently, named Janeth.  As I've been pinch-hitting on Rachel's off days from the hospital, I've seen her twice this week.  She is infected with HIV, and the infection has progressed to AIDS.  She came in with severe difficulty in breathing, very low oxygen levels, and an X-ray of her chest which just shows some vague opacities on both sides.

I have seen this case dozens of times.  It is the nondescript "HIV and lung disease" case, where they are very sick, and you're not sure what the cause is.  The primary offenders of concern are a wicked "normal" pneumonia, pulmonary tuberculosis (which is more common and severe in AIDS), and PCP pneumonia (which is reserved for patients with bad immune systems).  There are a slew of other possibilities:  MAC pneumonia, CMV pneumonia, pulmonary embolism, pulmonary Kaposi's sarcoma... but we have little in the way of diagnostic or therapeutic help for these, so we stick with the Big 3.

Part of me always wishes we could just choose one, or start with one and add other therapy if it doesn't work.  That's nice and clean medicine, like what I was taught in the US.  But it is a luxury that we give up.  This lady, and others like her, are too sick.  We cannot wait.  We will just be grateful if they make it out the other side of this illness, in time to get started on HIV meds, and maybe start their lives again.

A similar triad exists in Pediatrics.  The "Comatose kid already treated elsewhere who was referred here due to lack of improvement".  The triad is Bacterial Meningitis, TB Meningitis, and Cerebral Malaria.  Initially, in a desire to avoid unnecessarily committing a kid to more than 6 months of TB meds, I would hold off to see if they improved with therapy for the other two.  I changed my mind.  They are too sick.  I will always be happy if they survive.

This is, in fact, a general paradigm shift for medicine here.  My training tells me to do things for reasons of finding a sure diagnosis, reassurance, or piece of mind.  Here, we are often shooting in the dark, and I don't mind using a shotgun, if it means I hit the mark nonetheless.

So, 2 antibiotics for pneumonia, 4 meds to cover tuberculosis, horse doses of Bactrim to cover for PCP, and steroids to help the Bactrim, given how bad her PCP is.  As much oxygen as we can blow.  Prayers for her and her family.  Last night, she stopped breathing.  The intern was called, and when she came to write the death certificate, she was found to be breathing again (? I'm only reporting what I was told).  Now she is conscious again, able to talk a little, but looks terrible, and her oxygen level is 65%, several marks lower than what we would consider compatible with consciousness.

Pray for her.  We will continue to do what we can.  Outlook is poor.  But, on the other side, it will be her survival that will determine the quality of our style of medicine, and it's a bit surprising how I have grown accustomed to that.

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