A 32 year old man with HIV infection and a CD4 cell
count of less than 10 cells/mm3 complained of back pain. On the day of
admission he had been attacked by a dog and came to the emergency room,
both for care from the dog-related injuries, as well as for an evaluation
of his back pain. He reported a longstanding history of back pain since
he had been in a motor vehicle accident 11 months prior. The pain had
recently become much worse and was now localized in the mid-thoracic spine,
as well as in the lumbar area. He reported daily fevers to 105° F
over the past several weeks, along with a 10 pound weight loss over the
preceding month. He denied any loss of lower extremity strength or sensation,
as well as any episodes of incontinence.
Medications
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His medications included stavudine, lamivudine, dapsone, and clotrimazole troches. He also received directly observed isoniazid chemoprophylaxis through the health department for the past 2 months. He reported a febrile reaction to AZT and trimethoprim-sulfamethoxazole.
Past Medical
History
1. HIV infection diagnosed 3 1/2 years prior, with no
history of opportunistic infections. 2. Reactive tuberculin skin test
(7 mm induration) 2 months prior, with initiation of preventative therapy
following documentation of a normal chest radiograph. 3. Addiction to
heroin and cocaine, with daily injection use until 3 1/2 years prior,
now in recovery by his report.
Social History
Social history was also notable for release from the
state prison 6 months earlier following 3 years of incarceration. He has
since lived with his mother who is well. Review of Systems Review of systems
was otherwise notable only for a chronic non-productive cough.
Physical Examination
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He was a thin man and appeared uncomfortable. Temperature was 38.3°, respirations 24/min, pulse 76/min, blood pressure 120/76. Skin exam revealed abrasions on the elbows resulting from the dog attack, and head and neck exam revealed a swollen upper lip and moderate thrush in his oral pharynx, but no other abnormalities. The chest, cardiovascular system, and abdomen were normal. There was point tenderness of the lower thoracic spine, with an angular bony deformity visible at the T12 level. Neurologic exam showed diminished motor strength (4 of 5) of the lower extremities. Deep tendon reflexes were 1+ throughout, except for ankle reflexes, which were absent. The plantar reflexes were flexor.
Laboratory Results
The hematocrit was 32.3%, WBC count 4400/mm3,
and platelet count 230,000/mm3. Serum electrolytes, BUN and creatinine
were normal. Alkaline phosphatase was 184 IU/L (normal 50- 130). The erythrocyte
sedimentation rate was 120mm/hr. The chest radiograph showed no infiltrates
or effusions.