An AIDS patient with fever and pancytopenia

A 55;year-old white male with a diagnosis of acquired immunodeficiency syndrome (AIDS), based on a low CD4 count, for more than 3 years presented with a 3-week history of fever, drenching sweats, and a IO-pound weight loss. He denied rigors, headache, diarrhea, abdominal pain, visual changes, cough, dyspnea, or rash. The fevers were of gradual onset and reached 40°C on several occasions. Despite fevers, he was fully ambulatory and able to carry out his daily activities. The patient lived in Hawaii and had travelled extensively on business during the previous 2 years, to the Philippines, Indonesia (Jakarta), Peru, and northern Thailand. His most recent travel was to the Philippines 4 months prior to his presentation. There was no history of animal exposure. He had taken appropriate prophylaxis for travel in malarial areas. He had no prior opportunistic infections or hospitalizations. A CD4 count was 3O/p,L. He was PPD negative and had no known tuberculosis exposure. Granulocyte colony stimulating factor had been administered intermittently for 3 months prior to presentation for neutropenia. A bone marrow examination had not been performed. Other medications included stavudine, lamivudine, rifabutin, and trimethoprim/sulfamethoxazole. On admission for neutropenia and fever, the patient appeared well nourished and in no distress. His temperature was 40°C the heart rate was 100 bpm, the respirations were 18 per minute, and blood pressure was 1 lo/64 mmHg. Physical examination was remarkable only for hepatosplenomegaly. There was no adenopathy, abdominal tenderness, or skin rash. Laboratory examination was significant for pancytopenia, with a hematocrit of 23.9% and a white cell count of 500/mm3 with 65% granulocytes, 12% bands, 24% lymphocytes, and 1% monocytes. Platelets were 65,000/mm3. Liver function test results were slightly elevated; the