Manuscrito aids

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THE CHALLENGE OF DIAGNOSING AIDS IN THE ELDERLY

Authors: André Macedo Serafim Silva a, Guilherme Sousa Ribeiro b,c

a Internal Medicine Department – Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
b Gonçalo Moniz Research Center, Oswaldo Cruz Foundation, Brazilian Ministry of Health – Salvador - Brazil
c Institute of Collective Health, Universidade Federal daBahia – Salvador – Brazil

Electronic addresses: macedosera@gmail.com; gsribeiro@gmail.com

Corresponding author: Guilherme S. Ribeiro
Instituto de Saúde Coletiva, Universidade Federal da Bahia
Rua Basílio da Gama, s/n - Campus Universitário Canela, quinto andar
40.110-040 – Salvador-BA
Tel: +55 71 3283-7409







Abstract
Diagnosis of acquired immune deficiency syndrome (AIDS) andopportunistic infections among the elderly population attending the emergency room is frequently a difficult task. The clinical manifestations of HIV infection in older adults are nonspecific and the symptoms often are attributed to other diseases that are common in this age group. We present and discuss a case of an 82-years-old woman seeking for health care during three months of progressiveheadache. At emergency department she had unremarkable physical examination. A lumbar puncture was performed and revealed 5 white mononuclear cells/microL, 53 mg/dL of glucose and 30 mg/dL of protein. India ink staining showed images suggestive of Cryptococcus sp. The HIV test was positive and treatment for cryptococcal meningitis and AIDS was initiated. A gastroesophageal moniliasis was alsodetected and treated. The patient improved of the symptoms and was discharged after 32 days to AIDS reference service. This case highlights the importance of considering cryptococcal meningitis as a differential diagnosis in patients presenting chronic headache, even in older patient. Furthermore, HIV infection must not be neglected in the elderly subgroup as an increasing cause of immunodeficiency. Ahigh index of suspicion is required for early diagnosis of cryptococcosis and AIDS in older patients.

Keywords
Cryptococcus; Meningitis; HIV; Acquired Immunodeficiency Syndrome; Aged.


Case Report
An 82-year-old female patient, coming from a small countryside city of northeastern state of Brazil, presented to the infectious emergency department complaining of a 3-months history oflow-intensity headache. Initially, it was on the occipital region, oppressive and intermittent. Over the past week it had become generalized, continue and more intense, followed by persistent dysphagia and epigastric pain impairing her normal daily activity. Nausea and vomiting were frequent during the last twenty-four hours. She denied, fever and weight loss. The patient had a history of hypertension,taking regularly hydrochlorothiazide and amiloride. She denied any sexual activity in the last 23 years, when she became a widow. She also denied blood transfusion, previous surgery, intravenous drug use, neither direct contact with soil or birds. On admission the physical examination showed a well looking patient with normal vital signs and mental status. The examination of the oropharynx, heart,lungs and abdomen was unremarkable. Neurological examination was normal, and nuchal rigidity was absent. A brain computed tomography (CT) scan undertaken two weeks before admission revealed demyelination of periventricular white matter and mild supratentorial ventriculomegaly. A lumbar puncture was performed. Opening pressure was 25 cm/H2O. Cerebrospinal fluid analysis revealed 5 white mononuclearcells/microL, 53 mg/dL of glucose and 30 mg/dL of protein. India ink staining showed capsulated round images suggestive of Cryptococcus sp. The latex agglutination for cryptococci antigen test in the cerebral spinal fluid was positive, but the fungal culture was negative. Total blood cell count, renal function, serum electrolytes and chest radiography were normal. A test for HIV was positive....
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