N512 Disorders of the Immune System Final Project

Derek Smith, a 31 y.o.,  Caucasian male injection drug user, who is homeless, presents to the ED with a chief complaint of shortness of breath. He describes a 1-month history of intermittent fevers and night sweats associated with a nonproductive cough. He has become progressively more short of breath, initially only with exertion, but now he feels dyspneic at rest. He appears to be in moderate respiratory distress. His vital signs are abnormal, with fever to 39°C, heart rate of 112 bpm, respiratory rate of 20/min, and oxygen saturation of 88% on room air. Physical examination is otherwise unremarkable but notable for the absence of abnormal lung sounds. Chest x-ray film reveals a diffuse interstitial infiltrate characteristic of pneumocystis pneumonia, an opportunistic infection.

In this discussion:

1. Describe and discuss with your colleagues the underlying disease most likely responsible for this patient’s susceptibility to pneumocystis pneumonia.
2. Describe and discuss the immunosuppression caused by this underlying disease.
3. Describe and discuss the natural history of this disease and some of the common clinical manifestations seen during its progression.
4. Describe your plan of care for this patient following his hospitalization (he will likely be admitted to the “medical respite floor,” of a local homeless shelter, which has the services of a Nurse Practitioner three times per week—with on-call weekend consultation, and a registered nurse, Monday through Friday).

Include citations from the text or the external literature in your discussions.

Remember to respond to at least two of your peers. Please refer to the Course Syllabus for Participation Guidelines & Grading Criteria.

Sample Discussion 8 Approach

Mr. Smith, a 31-year-old homeless Caucasian male, presented in the emergency department (ED) with a chief complaint of shortness of breath (SOB). Mr. Smith states his SOB is becoming more apparent when at rest when previously he was only experiencing SOB on exertion. Mr. Smith also described having night sweats associated with a non-productive cough.

On physical assessment, Mr. Smith appears to be in moderate respiratory distress, using ancillary muscles while breathing and appears more dyspneic at rest. His vital signs (VS) are abnormal with temperature (T) 39.^C/102.^F, heart rate (HR) 112 bmp, respiratory rate (RR) of 20/min, and O₂ saturation of 88% in room air despite normal lung sounds heard. On assessment, it is noted that Mr. Smith has track marks denoting that he may potentially be an intravenous (IV) drug user for which he does not deny. Chest x-ray (CXR) and bloodwork were obtained to verify the potential diagnosis.

Human Immunodeficiency Virus (HIV)

HIV is an RNA-based retrovirus that attacks the CD4⁺ cells/T helper cells that help fight infection causing the CD4⁺ to be dysfunctional (Hammer & McPhee, 2019, pp. 31-57). HIV can be spread through a blood transfusion of infected blood, by infected individuals having unprotected sex, contact with infected bodily fluids as seen with intravenous drug users sharing paraphernalia as seen with Mr. Smith, or via transport from mother to fetus as infected blood crosses the placental barrier, delivery or through breastfeeding (Pathophysiology Made Incredibly Easy!, 2019, pp. 362-370).  

According to (What Are Opportunistic Infections & Hiv, 2020) there are three stages of HIV infection:  

1)    Acute HIV infection:

During this first stage, potentially within two-four weeks after infection, some patients may not have symptoms, while others may feel flu-like symptoms as the body’s response to the infection; symptoms including chills, fever, rash, night sweats, sore throat, muscle aches, swollen lymph nodes, fatigue, and even mouth ulcers. The virus, even though it is in the beginning stages of HIV, you are at high risk for infecting others. N512 Disorders of the Immune System Final Project

2)    Clinical latency or chronic HIV infection:

Individuals affected may or may not have symptoms as seen in stage 1. If you are on medications, keeping your viral load undetectable, you not only protect yourself but protect your partner. It is when you have a detectable viral load you place yourself at risk for opportunist infections while putting your partner at risk transmitting the virus to him/her. Some people will stay in this stage without treatment for approximately 10 or 15 years; however, some will move faster through this stage on to the third stage since the virus still multiplies at low levels.

3)    Acquired Immunodeficiency Syndrome (AIDS) or late-stage HIV:

Without appropriate treatment, your immune system will weaken and eventually be destroyed exposing you to AIDS. Symptoms of AIDS can include rapid weight loss, extreme fatigue, prolonged swelling of lymph nodes, diarrhea lasting more than a week, fever, profuse night sweats, sores in the mouth, anus, or genitals, or pneumocystis pneumonia (PCP), one of the most common opportunistic infection caused by the fungus, pneumocystis jirovecii, as seen in Mr. Smith. Even though PCP is rarely seen in healthy individuals due to their properly functioning immune system, an individual with a compromised immune system cannot fight the infection. The patient may experience memory loss, depression, and other neurological disorders (What Are Opportunistic Infections & Hiv, 2020).

Throughout these stages, the ranges of CD4⁺T Lymphocytes:

            Category 1: CD4⁺cell count greater than or equal to 500

            Category 2: CD4⁺cell count 200 to 499

            Category 3: CD4⁺cell count less than 200 (Pathophysiology Made Incredibly Easy!,

2019, pp. 362-370).

It is best to get tested if questioning whether you were potentially exposed to HIV by infected blood or body fluids from an infected person/partner. You cannot rely on the above symptoms to denote HIV since these symptoms can also be seen in other disease processes; therefore, you must be specifically tested for HIV. Timing is everything, testing negative potentially means that you have not built up antibodies yet, needing to be retested approximately 45 days after most recent exposure (Pathophysiology Made Incredibly Easy!, 2019, pp. 362-370).

If you are not HIV positive, the test will not show antibodies responsible for HIV, and there are preventative measures, pre-exposure prophylaxis (prEP), you can take to help you stay negative; however, if positive, there are medications that you can take to keep your viral load at an undetected level (What Are Opportunistic Infections & Hiv, 2020). HIV patients are at risk for many opportunistic infections as a result of the immune system malfunction with the CD4/T-lymphocyte count decreases, as seen above. Your dysfunctional immune system cannot defend the invasion thus, moving through the stages of HIV to AIDS causes many illnesses like dementia, wasting syndrome, and blood abnormalities (Pathophysiology Made Incredibly Easy!, 2019, pp. 362-370).

In Conclusion

During hospitalization, Mr. Smith will be placed on oxygen (O₂) to help with his respiratory needs while monitoring his vitals. An antibiotic, co-trimoxazole, will be given via IV to treat the opportunist infection, PCP while in the hospital, if not sensitive to sulfamethoxazole medications (HIV, 2020). A prescription will be given when discharged to be taken by mouth (PO) to assure the treatment of three weeks will be provided (HIV, 2020).  

Mr. Smith will require a lot of education regarding HIV/AIDS focusing on transmission while decreasing the potential risks of opportunistic infections including bacterial infections, viral infections, fungal infections as seen with PCP, protozoan infections, as well as unusual neoplasms causing cancer due to the compromised immune system. Mr. Smith will be placed on anti-retroviral medications, with strict education provided on usage.

As an outpatient, lab work will be obtained making sure that the anti-retroviral (ART) therapy is effective, as seen by a decreased viral load. Mr. Smith will be placed in an out-patient drug treatment plan/program to decrease his need for IV drugs and/or other potential drugs utilizing subutex or methadone drug therapy if meeting criteria while making sure there are no interactions with the anti-retroviral medications.

I would like to see Mr. Smith’s partner tested for HIV. It would be a good idea if both Mr. Smith and his partner were tested for sexually transmitted diseases (STDs) as well. Sputum culture and/or CXR will need to be obtained after antibiotic treatment concludes to make sure the PCP infection has cleared. I am glad there will be a Registered Nurse (RN), as well as a Certified Nurse Practitioner (CNP) available on-site at the homeless shelter to monitor Mr. Smith’s condition, or as the need arises. I will be requesting Mr. Smith has a social work consult in place before leaving the hospital so there will be no interruption of medication usage as this will be a strict regimen to be followed for the rest of his life (VHA Office of Mental Health, 2020).

Hammer, G. D., & McPhee, S. J. (2019). Pathophysiology of Disease: An Introduction to Clinical Medicine 8E (8th ed.). McGraw-Hill Education / Medical.

HIV. (2020). Www.CDC.Gov. https://www.cdc.gov/hiv/group/gender/men/index.html

VHA Office of Mental Health. (2020). VA.gov | Veterans Affairs. VA. https://www.va.gov/HOMELESS/for_the_community.asp

What are opportunistic infections & hiv. (2020). HIV.Gov. https://www.hiv.gov/hiv-basics/staying-in-hiv-care/other-related-health-issues/opportunistic-infections. N512 Disorders of the Immune System Final Project