Friday, April 13, 2012


     I have seen HIV cases for many years. Some cases are easy, and obvious and the diagnosis is even expected by the patient. And then there are cases it hits you suddenly . In the past we in medical profession were not aware of the incidence and were not expecting it . But then as the time went on and we saw many different presentations of the HIV , it became less of a ' mystery ' or unusual case . Never the less I still remember many of those unusual cases , simply because of the presentation. In those days diagnosis of HIV was death sentence '. And so it was very difficult to talk about it. The story that I want to tell occurred in early 80es.
    I saw a new patient , who  was referred to me by one of the family doctors. Patient was complaining of cough and so the doctor did chest x-ray. The x-ray came back abnormal . So he was asked to see me . He was 35 years old male , who had smoked in the past , but had quit 10 years ago. He was not alcoholic and had never used 'drugs' . He had mild asthma and worked as 'friut inspector '. He was having some cough, not much sputum, and questionable night sweat and weight of 5 lbs. He had brought in his x-ray and it showed some 'congestion ' in both lungs . i.e. bilateral diffuse infiltrates. His physical examination was normal . I did not feel any lymph node enlargement. At most I heard some crackles in lungs .
     There were no old x-ray available for the comparison. So my feeling was  that he may have  a condition called sarcoidosis .In this condition patients develop nonspecific inflammation in the lungs and they also develop lymph gland swelling in the chest and common symptom , if at all , they have any is dry cough. Sometimes thy may be short of breath.
     So I decided to do ct scan of the chest and scheduled him for the 'endoscopy ' (bronchoscopy- to look inside lungs and do biopsy ). The ct scan confirmed the chest x-ray finding and the bronchoscopy was uneventful . It was Thursday and  it was going to be Easter week end . So I was trying to finish the work in the office . And I got a call from the pathologist. Usually we get these calls only when it is cancer or something questionable or unusual and the pathologist wants additional history.
     When I picked up the phone , he asked me the history . and told him what my presumptive diagnosis was. He said ' well what I am seeing is not sarcoidosis, but I am seeing PCP. ' I was speechless. PCP pneumonia all most exclusively occurs in immune compromised patient, like HIV. My patient did not 'fit ' in to the typical patient that would get HIV and the PCP pneumonia. My second problem was how to tell patient . The weekend was coming and I wanted to treat him and tell him the diagnosis of PCP and do the test for confirming the HIV. But I COULD NOT DO IT IN THE TELEPHONE . So what could I tell him on the telephone, that too on Easter weekend? .
     I decided to call him and tell him the truth, but not the 'whole ' Truth . ( I had heard cases where patients had committed suicide after knowing the diagnosis . ) I had to be careful . I told him that I got some reports from the tests and I could not treat him at home . The medicines needed to treat  the type of pneumonia he had were given intravenously and so he needs to be in the hospital . He agreed.
    In the hospital, I told him the type of pneumonia and possibility of HIV and need to the test to confirm the diagnosis. He agreed . And then he told me something that I had not asked him , nor did he volunteer before. He told he that he was homosexual.
  I was somewhat surprised but not fully . But then what he asked me was more than what I could have anticipated or handled .
    His parents did come to the hospital , flew in from CT . I had to sit with them on the Easter Sunday and tell them the diagnosis. It was very hard . But after all the information was told to them , they accepted it.

(This  type of the story  may not be that may occur today , as many parents have told their parents about the 'lifestyle' and HIV patients live for many years and HIV is not a death sentence , that it used to be .)

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