A 53-year-old woman consults for a fever of 15 days of evolution, without symptoms of infectious focality. On examination, a painful hepatomegaly is detected at 5 cm from the costal margin and the spleen is palpated at 14 cm from the left costal margin. The blood count showed Hb 8.5 g/dL, leukocytes 630/ml (lymphocytes 63%, monocytes 20%, neutrophils 17%) and platelets 35,000/ml. Biochemistry shows moderate elevation of liver biochemistry, LDH is normal and polyclonal hypergammaglobulinemia (3.5 g/dL) is observed in the proteinogram. He has a history of known HIV infection for 10 years and irregular adherence to antiretroviral treatment, with recent determinations of CD4 lymphocytes 350 cells/mL and HIV viral load of 154 copies/mL. For the past 3 months she has been treated for seronegative symmetrical polyarthritis with 10-20 mg/day of prednisone. Which of the following statements is correct?
Easy and quite typical question. We are told about an HIV patient with irregular follow-up of antiretroviral treatment, presenting fever, hepatosplenomegaly, pancytopenia and polyclonal hypergammaglobulinemia. All these data are suggestive of visceral Leishmaniasis, so an OM biopsy should be performed to look for amastigotes and confirm the diagnosis.
I would perform a bone marrow biopsy, since the most probable diagnosis is visceral leishmaniasis.
Pancytopenia is justified by C virus-associated cirrhosis and I would not perform further testing.
Probably a medullary toxicity due to prednisone that would be treated with drug withdrawal and filgastrim.
I would request an ANAs determination to rule out disseminated systemic lupus.
I would intensify antiretroviral therapy, as it is likely that all manifestations are due to HIV.
All these data are suggestive of visceral Leishmaniasis, so an OM biopsy should be performed to look for amastigotes and confirm the diagnosis.