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What is going on?
Jan 24, 2011

Dr. Frascino, my partner has newly diagnosed AIDS. In October of 2010 at dx, his CD4 count was 5 and his viral load was 968,000. The end of December 2010 his viral load was 800 and CD4 147. He was doing well. Last week Thursday he woke up short of breath. I took him to the ER and he was diagnosed with an acute cardial effusion. He had a pericardial window procedure today and they removed 452 ml of fluid. The ID doctor sent the pericardium portion from the window to pathology and the fluid for culture and other tests. He also told us that my partners CD4 is now 72 and the percentages are down also. He is not concerned for treatment failure because the viral load is also down from 800 to 100. I asked him what would cause an acute percardial effusion and also the CD4 count to drop like that in 3 weeks time frame. He did not have an answer. Is there something he could be missing in the big picture here? At diagnosis in October cultures for MAC were negative. I am not convinced because as his immune system is waking up, he is getting joint pain everywhere. Any ideas? Any suggestions? What should I be asking the ID specialist? Thanks!

Response from Dr. Frascino

Hello,

It is difficult for me to comment specifically, based on the limited information presented. It is possible your partner is experiencing immune reconstitution syndrome (IRS), which is an atypical inflammatory disorder associated with immune recovery. It results from qualitative and quantitative recovery of pathogen-specific cellular and humoral immune responses and has been noted to occur with multiple opportunistic pathogens, including mycobacterium tuberculosis, mycobacterium avium complex, cytomegalovirus, Epstein-Barr virus, hepatitis B and C, candida albicans, Kaposi's sarcoma and pneumocystis jiroveci among others. MAC accounts for about one third of the reported cases, but certainly is not the only opportunistic pathogen capable of inducing IRS.

I agree with what your partner's ID specialist has done so far -- sending the tissue to pathology and fluid for culture and analysis, etc. I don't think he is missing anything. I'm assuming your partner's ID specialist is an HIV/AIDS specialist. If not, your partner should establish care with an HIV specialist as well. An HIV/AIDS specialist will be able to give a more specific response to your question regarding fluctuations in your partner's absolute CD4 counts. (This is most likely due to his intercurrent illness.) In addition, he should provide information on how we monitor treatment efficacy virologically (HIV plasma viral load) and immunologically (CD4 count, CD4%). Close follow-up is warranted, as your partner's immune system has been very severely compromised by HIV, leaving him susceptible to many opportunistic infections and malignancies and their complications.

Dr. Bob



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