An HIV-infected boy with severe rash after starting highly active antiretroviral therapy (Page 1/2)

Prepared by...
Podjanee Jittamala, M.D.
Peninnah Oberdorfer, M.D., Ph.D
Virat Sirisanthana , M.D.
Department of Pediatrics, Faculty of Medicine, Chiang Mai University
A 9- year-old HIV-infected boy
Refered from a district hospital, Chiang Mai, Thailand
Chief compliant: Fever with rash for 2days
Present illness:
> He was diagnosed as an HIV-infected child when he was 3 year old.
> 13 days prior to admission, he was started on highly active antiretroviral therapy (HAART). His absolute CD4 cell count was 137 cell/mm3( 11% CD4) prior to HAART.
  As the choosen HAART regimen was GPOvir-Z (zidovudine 250mg, lamivudine 150mg and nevirpine 200mg), his 2-week lead-in period drugs consisted of GPOvir-Z 1/2 tablet at 7.00 am, zidovudine (100mg tablet) 1.5 tablet and lamivudine (150mg tablet) 1/2 tab at 7.00 pm. were started 13 days ago.
> He did not receive any other medicine other than these antiretroviral drugs.
> 2 days prior to admission (on the 11th day of HAART), he developed high fever with skin and mucous membrane lesions. He was seen at the district hospital and referred to be admitted at our hospital for the management.
Past history:

The patient was diagnosed as an HIV-infected child since 3 years of age. He has never experienced any illnesses due to his immune deficiency syndrome.

Family History:
  He is an orphan. He has been living in an orphanage since he was 3 years of age.

Physical examination:
GA: An appearing sick cachetic boy with good consciousness
V/S: T 38.8 C (highest peak in the first 48 hours was 39.4 C), PR 100/min, RR 24/min, BP 120/60 mmHg
HEENT: Ulceration with formation of peudomembranous mucosa at both lips with oral mucosal erythema. There was also the mucosal involvement of nasal canals, marked suffusion of both eyes. (Figure 1 – 7)
Pharynx and tonsils can not be evaluated.
Normal tympanic membranes, bilaterally
Lymph node: can’t be palpable
Heart: no murmur, normal S1,S2
Lung: clear, no adventitious sounds
Abdomen: soft, normal bowel sounds, liver and spleen were not palpable
Extrimities and Skin: diffuse erythematous papules, vesicles, small hemorrhagic bullae, urticarial plaques, and confluent erythema on the face, chest wall, trunk , upper and lower limbs including palms and soles.
Genitalia: small hemorrhagic bullae and peudomembranous plaques at the penis (figure 8)
Figure 1
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Figure 8
Problem list:
Fever, rash with multiple mucosal site involvement in an HIV-infected boy who has been on highly active antiretroviral therapy (HAART) for 11 days

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