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Case of the Month - October 2013

Helena Rabie, Rabeen Lutchman and Mark Cotton Tygerberg Hospital

A 6-year-old HIV infected boy who previously defaulted antiretroviral therapy, presented with a chronic cough that worsened in the prior 4 weeks. He also complained of increasing shortness of breath and fever for the past 3 weeks.

He had presented to his local clinic in the 3 months prior to admission, and been diagnosed with pulmonary tuberculosis based on symptoms and a suggestive chest radiograph. Sputum smear was negative and culture not requested. At this time his HIV viral load was log 4.64 copies/ml and the CD4 count 2 cells/mm3.

Therapy with rifampicin, isoniazid, pyrazinamide, abacavir, lamivudine, and efavirenz was started at the local clinic.

His mother regularly attended tuberculosis and antiretroviral clinic and on interview, a good understanding of medication routine was noted.

Examination revealed a chronically ill-looking boy with acute, severe respiratory distress requiring supplemental oxygen

His HIV viral load on admission had suppressed and his CD4 count had increased to 210 cells/mm3. Sputum smear was positive for acid fast bacilli.

Question 1: What is the differential diagnosis?

Continue to Answer 1