| A |
guangyu |
1 |
5% |
| B |
drdadi, ansalshah |
2 |
10% |
| C |
aspire, inkspot, lq2006, toofar, CocaCola, milestogo, smalley, nemdas |
8 |
38% |
| D |
cool doctor, multani001, nyimalay, bharatvedin, khiladi |
5 |
24% |
| E |
drems, Justice, yogesh, doc649, vijay1900 |
5 |
24% |
| Author | 9 Posts |
Justice
Forum Fanatic
Topics: 100
Posts: 1,930
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Please vote with your answer
A 29-year-old man was found to have late-stage HIV infection at the time of diagnosis of pulmonary tuberculosis. His initial CD4 cell count was 17/μL with a plasma HIV RNA viral load of 33,520 copies/mL. Cough and fever quickly improved following treatment with a three-drug antituberculous regimen (isoniazid, rifampin, and pyrazinamide) and a three-drug antiretroviral regimen (zidovudine, lamivudine, and abacavir). At a follow-up visit 4 weeks later, he reports recurrent fevers as well as neck pain and swelling. On physical examination, temperature is 38.4°C (101.1 °F). Other vital signs are normal. His weight is unchanged. Examination of the neck discloses bilateral enlarged, tender, fluctuant lymph nodes. The spleen tip is palpable. A chest radiograph shows a new pleural effusion. Lymph node aspirate reveals no organisms on acid-fast stain.
Which of the following is the most appropriate management at this time?
A. Add ethambutol to the antituberculous regimen
B. Substitute efavirenz for abacavir in the antiretroviral regimen
C. Obtain an excisional lymph node biopsy
D. Perform a diagnostic thoracentesis
E. Treat symptomatically for pain and fever
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| inkspot
Forum Guru
Topics: 26
Posts: 557
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disseminated TB or lymphoma? i think the latter .
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| guangyu
Forum Elite
Topics: 29
Posts: 308
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A?
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| milestogo
Forum Newbie
Topics: 3
Posts: 33
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im thinking imaybe diagnostic thoracocentesis is better idea
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| yogesh
Forum Newbie
Topics: 5
Posts: 56
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E. Immune Reconstitution???
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| inkspot
Forum Guru
Topics: 26
Posts: 557
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c and d are both very strong candidates.
new effusion in joints , ascities, pleural effusion, pericardial effusion, etc has to be drained for making a diagnosis ( as kaplan says dont assume a patient with CCF to have a transudate - do the test )
on the other hand
neck discloses bilateral enlarged, tender, fluctuant lymph nodes =-= warrants further evaluation specially when the aspirate turns out to be negative for TB.
Looking back: i think D is more likely to be the correct answer, since painful LN are not likely to be neoplastic as i in my previously post thought.
justice are you back from your trip. when can we expect the answers 
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| Justice
Forum Fanatic
Topics: 100
Posts: 1,930
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The correct answer is E
This patient presents with paradoxical worsening of his tuberculosis following the initiation of antiretroviral and antituberculous therapy. Such reactions are thought to be due to partial immune reconstitution, which occurs following effective control of HIV by antiretroviral therapy. This type of immune reconstitution syndrome reaction has also been described in patients with other AIDS-related opportunistic infections, including disseminated Mycobacterium avium complex infection and cytomegalovirus retinitis.
This patients findings are unlikely to be due to failure of either treatment regimen. His current treatment should therefore be continued along with the addition of a nonsteroidal anti-inflammatory drug for control of pain and fever. Lymph node biopsy and diagnostic thoracentesis are unlikely to be harmful, but are probably unnecessary at this time. Although not listed as an option, some clinicians advocate administering short, tapering courses of corticosteroids is advocated by some clinicians. To date, however, no large published series have addressed the safety or efficacy of this approach.
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| yogesh
Forum Newbie
Topics: 5
Posts: 56
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Yesssssssssss...
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| inkspot
Forum Guru
Topics: 26
Posts: 557
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thats really clever of you yogesh
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