Clinical Images

Rash and Shortness of Breath

 Navabi N, Scott M, M Montebatsi, Reid MJA

A 45 year-old HIV-infected male presented to a rural hospital in southern Botswana with breathlessness and diffuse non-pruritic, non-tender rash. These symptoms had worsened over the previous week, and were accompanied by lethargy, subjective fevers and dry, non-productive cough.  He had started antiretroviral therapy four months earlier. 

On examination, he was ill-appearing; temperature was 36.7 degrees Celsius, blood pressure was 145/87 mmHg, pulse was 115 beats per minute.  Oxygen saturation was 75% on room air and respiratory rate was 45 breaths per minute.  Crackles were heard at the lung bases bilaterally. He was alert but disoriented to time and person. He had a diffuse, umbilicated, papular rash predominantly affecting the face, upper trunk and arms.   Many of the papules were ulcerated. No oral mucosal lesions were noted.

Routine laboratory results included a hemoglobin level of 11.1 g/dL, platelet count of 428 x 103/μL, white blood cell (WBC) count of 3800/μL (with neutrophils 88.8%).  Renal and liver function tests were normal.  His CD4 count was 25 cells/μL.

He was started on empiric therapy with cefotaxime, cotrimoxazole and prednisolone. Unfortunately his clinical status rapidly declined and he was transferred to a referral hospital on day seven. Chest radiography was subsequently performed and revealed diffuse bilateral alveolar infiltrates, more prominent in the lower lung fields.

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REFERENCES
1. Jarvis JN, Harrison TS. HIV-associated cryptococcal meningitis. AIDS 2007,21:2119-2129.
2. Amerson EH, Maurer TA. Dermatologic manifestations of HIV in Africa. Top HIV Med 2010,18:16-22.


Biographies

Nazlee Navabi saw this patient with the physician co-authors while abroad on a medical school rotation through the Botswana UPenn Partnership. She recently graduated from Perelman School of Medicine at the University of Pennsylvania and will start internal medicine residency at the University of Washington. 

Michelle Scott is a resident physician in dermatology at the University of Pennsylvania.

Milton Montebatsi is a medical attending at Princess Marina Hospital in Gaborone, Botswana.

Michael Reid is Assistant Professor of Medicine in the Division of Infectious Diseases at the University of Pennsylvania and is the lead physician for the Botswana UPenn Partnership Program.