Clinical Manual for Management of the HIV-Infected ... - myCME.com
Clinical Manual for Management of the HIV-Infected ... - myCME.com
Clinical Manual for Management of the HIV-Infected ... - myCME.com
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Fever<br />
Background<br />
Although fever may ac<strong>com</strong>pany <strong>HIV</strong> infection at<br />
various stages <strong>of</strong> disease, fever in a patient with a low<br />
CD4 count (101°F (38.3°C).<br />
Assess <strong>the</strong> following during <strong>the</strong> history:<br />
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Duration <strong>of</strong> fever<br />
Associated symptoms, including chills, sweats,<br />
weight loss<br />
Visual disturbances (see chapter Eye Problems)<br />
Nasal or sinus symptoms<br />
Asymmetric, tender, or new lymphadenopathy<br />
Cough or shortness or breath (see chapter Pulmonary<br />
Symptoms)<br />
Diarrhea, tenesmus (see chapter Diarrhea)<br />
Vaginal or urethral discharge<br />
Rash, lesions, s<strong>of</strong>t-tissue inflammation<br />
Pain (<strong>for</strong> headache, see chapter Headache)<br />
Neurologic symptoms (see chapter Neurologic<br />
Symptoms)<br />
O<strong>the</strong>r localizing symptoms<br />
Unprotected sexual contacts<br />
Recent injection drug use<br />
Travel within <strong>the</strong> past 6-12 months<br />
Intravenous line or venous access device<br />
Medications (as a cause <strong>of</strong> fever)<br />
Use <strong>of</strong> antipyretic agents including acetylsalicylic<br />
acid, nonsteroidal antiinflammatory drugs<br />
(NSAIDs), and acetaminophen; when was most<br />
recent dose?<br />
Hepatitis history<br />
O: Objective<br />
Section 5—Complaint-Specific Workups | 5–25<br />
Document fever. Check o<strong>the</strong>r vital signs, including<br />
orthostatic measurements. Check weight and <strong>com</strong>pare<br />
with previous values. Search <strong>for</strong> evidence <strong>of</strong> an infectious<br />
focus. Per<strong>for</strong>m a <strong>com</strong>plete physical examination,<br />
including evaluation <strong>of</strong> <strong>the</strong> eyes (including fundus),<br />
sinuses, oropharynx, lymph nodes, lungs and heart,<br />
abdomen, joints, genitals, uterus, rectum, and neurologic<br />
system. Review recent CD4 measurements, if available,<br />
to determine <strong>the</strong> patient’s risk <strong>for</strong> opportunistic illnesses<br />
as a cause <strong>of</strong> fever.<br />
A: Assessment<br />
The differential diagnosis varies depending on <strong>the</strong> CD4<br />
count. Partial lists are as follows.<br />
Conditions More Likely with Low CD4 Count<br />
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Aspergillosis<br />
Cryptococcosis<br />
Cytomegalovirus infection (CMV)<br />
Disseminated Mycobacterium avium <strong>com</strong>plex (MAC)<br />
Disseminated histoplasmosis<br />
<strong>HIV</strong> infection itself<br />
Lymphoma, o<strong>the</strong>r neoplasms<br />
Pneumocystis jiroveci pneumonia (PCP)<br />
Sinusitis<br />
Toxoplasmosis<br />
Tuberculosis (atypical or extrapulmonary)<br />
Conditions That May Occur at Any CD4 Count<br />
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Acute hepatitis<br />
Bacterial pneumonia or bronchitis<br />
Tuberculosis (pulmonary)<br />
Urinary tract infection (UTI)<br />
Otitis<br />
Endocarditis<br />
Abscess, cellulitis<br />
Bacteremia or sepsis<br />
Disseminated herpes simplex virus; chicken pox
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