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A 5-year-old HIV-infected boy with rash and abdominal pain (page 1/3)

Prepared by...
Virat Sirisanthana, M.D. *
* Department of Pediatrics, Chiang Mai University
Patient: A 5-year-old HIV-infected boy Address: Chiang Mai
CC: vesicular skin lesions, abdominal and chest pain for a few days.
Present Illness:
He is a known case of HIV-infected boy. He has had several episodes of "acute febrile illness" and "diarrhea" since he was 3 years old. His weight and height were at the 10th percentile and his CD4 T-lymphocyte count was 4% while he was started on antiretroviral therapy (GPOvir30) (ART) a month ago. He was not given primary PCP prophylaxis for fear of added adverse event in combination with
antiretroviral therapy.
10 days PTA he was exposed to a person with chickenpox.
4 days PTA he started having low grade fever.
2 days PTA his mother noticed a few papular rashes at his face and trunk. He complained of abdominal pain, but he had no nausea or vomiting.
Famillyl History:

His father died with pulmonary disease 2 years ago. His mother was diagnosed as mild symptomatic HIV-infected woman a few months ago. His elder brother was healthy.
Physical examination:
  GA: BW 16 kg (10 percentile), HT 104.5 cm (10 percentile)
Vital signs: BT 37.5 C (highest temp in the first 24 hours of admission), PR 100/min, RR 56/min, BP 100/60 mmHg.
HEENT: WNL.
Lymph nodes: No significant cervical, axillary, or inguinal lymphnode enlargement.
Heart: normal S1,S2, no murmur.
Lungs: fine crepitation both lungs.
Abdomen: generalized tenderness, no rebound tenderness, liver 2 cm below RCM, spleen 2 cm below LCM
Extremities: no edema
Skin: generalized multiple macules, papules and vesicles over body, face scalp and extremities.
Neuroexam: no neurological deficit
Initial Laboratoy investigations:
  CBC: Hb 10.2 g/dL, Hct 31 %, WBC 2,200/mm3 (N58%, L27%, M13%, B1%, E1%) Platelet 113,000/mm3
  UA: WNL
  Abdominal X-ray: WNL
  CXR: as in figure 1 :
Figure 1 Chest X-ray
Problem list:
1. HIV-infected boy who has been on antiretroviral therapy (GPOvir-30) for one month. His CD4 T-cell prior to starting antiretroviral therapy was 4%.
2. Chickenpox
3. Pneumonia
4. His total lymphocyte count = 2200x27% = <1,500 : lymphopenia

What is the differential diagnosis for his pulmonary problem?
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