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elite controller?

Apr 17, 2010

One of my patients (diagnosed 2006), also co-infected with Hepatitis C had good CD4 counts >1000 until recently when CD4 has plunged to 61. Viral load has never gone beyond 71 copies. Patient has led a chaotic lifestyle in having regular bloods taken but last three VL's have been undetectable with no treatment! At last visit he presented with extensive pral candidiasis and flare up of psoriasis. he was placed on co-trimoxazole and fluconazole including preparations for the psoriasis.Clearly he now requires HAART, can you explain this? I always believed elite controllers also maintained a high CD4 response.

Response from Dr. Holodniy

I have never seen a real CD4 count decline from 1000 to 61 in such a short time frame. Did you repeat it? Given your description of oral candidiasis (in the absence of any antimicrobial administration) this would indicate some likely immunologic perturbation with loss of immunologic control. Is is also curious though, despite such a crash in CD4 count and symptomatic disease that the viral load has not increased. Some anecdotal cases have occurred with superinfection with another HIV strain leading to disease progression, but again I would have expected to see a viral load response to match the CD4 cell decline.

3 blips in a row, Is it time for a second opinion?

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