Download Newly diagnosed HIV infection in an octogenarian: the elderly are not

Age and Ageing 2003; 32: 353–354
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Age and Ageing Vol. 32 No. 3 # 2003, British Geriatrics Society. All rights reserved.
CASE REPORT
Newly diagnosed HIV infection in an
octogenarian: the elderly are not
‘immune’
G EOFFREY C. C LOUD1 , R ITA B ROWNE3 , N INA S ALOOJA2 , K ENNETH A. M CL EAN 3
1
3
Department of Elderly Medicine and 2Department of Haematology, Hammersmith Hospital, London, UK
West London Centre for Sexual Health, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
Address correspondence to: K. McLean. Fax: (q44) 208 846 7582. Email: [email protected]
Abstract
Case report: an 83-year-old heterosexual man with malaise tested positive for HIV infection antibodies and has
responded well to triple antiretroviral therapy.
Discussion: HIV should not be discounted on the basis of age when an elderly patient presents for the investigation
of illness.
Keywords: HIV, human immunodeficiency virus, elderly, heterosexual transmission
Case report
An 83-year-old West Indian man presented to the
geriatric outpatient department with a recent history of
shingles and weight loss.
In the past he had been treated for hypertension,
benign prostatic hyperplasia, autoimmune hypothyroidism
and pernicious anaemia. He had also had three previous
episodes of urethral gonorrhoea, the most recent episode
being 15 years ago and been treated for latent syphilis
when aged 40.
He had lived in England for 35 years, was unmarried,
heterosexual and lived alone independently.
Other than a reduced Body Mass Index of 19.3 and
minor post-herpetic scarring, clinical examination was
unremarkable.
Results of his blood tests showed a normochromic,
normocytic anaemia of 10.4 g/dl and ESR of 108 mm/h.
Other results are shown in Table 1. A bone marrow
examination was done which showed mild trilineage
dysplasia and non-specific reactive changes.
In the light of unexplained anaemia, leucopenia and
polyclonal increase in gammaglobulin with a monoclonal
band and a reactive bone marrow picture it was felt that
despite his age, HIV (human immunodeficiency virus)
infection should be considered. Pre-test counselling
indicated that he had never injected drugs, received a
blood transfusion nor had sex with men. Although he had
suffered from erectile dysfunction in the last 5 years, prior
to this he had had an active heterosexual sex life.
Our patient subsequently tested positive for HIV
antibodies with a total CD4 lymphocyte count of
Table 1. Results of initial laboratory investigations
Laboratory test results from initial clinic visit
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Haematology
Haemoglobin 10.4 g/dl
Mean corpuscular volume 83.4 fl
White blood cells 3.63109/l
Neutrophils 1.43109/l
Lymphocytes 1.83109/l
Platelets 2273109/l
B12/folate/Fe studies all normal
Erythrocyte sedimentation rate 108 mm/h
Biochemistry
C-reactive protein 3 mg/l
Renal biochemistry normal
Total protein 104 g/l
Albumin 27 g/l
IGG (5.3–16.5) 57.1a g/l
IGA (0.8–4.0) 2.25 g/l
IGM (0.5–2.0) 2.56 g/l
a
Faint monoclonal band detected on immunofixation.
Bence-Jones proteinuria not detected.
353
G. C. Cloud et al.
106 per mm3 (8% of total lymphocyte count). HIV viral
load was 173,000 copies/ml (Roche Amplicor).
He was started on triple antiretroviral therapy, and
co-trimoxazole as primary prophylaxis against Pneumocystis
carinii pneumonia (PCP). Within 4 months, his HIV viral
load became undetectable at ultrasensitive level, and
his most recent CD4 count is now 266. More than
18 months after starting treatment, he is well, fully
compliant and has celebrated his 85th birthday.
Key points
. HIV is a common infection and incidence and
prevalence are likely to rise in the ageing population.
. A sexual history is important to take in all patients
with an apparent infectious disease.
. HIV infection is an important differential diagnosis in
any patient with a cytopenia.
. HIV infection can present in the elderly and does
respond to anti-retroviral treatment.
Discussion
‘Older’ in the context of HIV infection has come to be
considered aged over 50 years [1]. As the global HIV
epidemic continues, the number of older patients with
HIV infection is likely to increase. However the size of the
problem in the elderly population is unknown. Most
seroprevalence studies have targeted parenteral drug users,
gay men, pregnant women, and genitourinary medicine
clinic attenders, and have not included many elderly
people. Fewer than 1% of reports of HIV in the UK are of
infections diagnosed at age 65 or over [2] and there has
been no previous report of a patient aged 80 or over
recorded as having acquired HIV infection heterosexually
according to UK PHLS data [3]. However studies of the
sexual behaviour of older adults have suggested that they
may be less aware of HIV risk factors and prevention
strategies and more likely to practise unprotected sex [1].
HIV infection may also not be considered in the
differential diagnosis by the patient or physician when
an elderly person is unwell. A retrospective review of 423
AIDS presenting illnesses in patients aged 60 years or over
showed PCP to be the most common condition, but the
diagnosis was often missed or delayed [4]. Post-mortem
testing of 257 patients aged over 60 years (not known to
be HIV positive) from one hospital in New York between
1992 and 1993 showed 6% of men and 9% of women
were HIV sero-positive [5].
This case illustrates that the possibility of HIV infection should not be discounted on the basis of age when an
elderly patient presents for the investigation of illness.
354
Acknowledgement
The authors would like to thank Janet Mortimer,
Principal Scientist, HIV AIDS Reporting Section of
the Public Health Laboratory Service, for her help in
preparing this report.
References
1. Stall R, Catania J. AIDS risk behaviours among late middleaged and elderly Americans. National AIDS Behavioural
Surveys Arch Intern Med 1994; 154: 57–63.
2. PHLS AIDS and STD Centre - Communicable Disease
Surveillance Centre, and Scottish Centre for Infection &
Environmental Health. Unpublished Quarterly Surveillance
Tables No. 54: 02/1, March 2002.
3. Personal Communication from PHLS CDSC, May 2002.
4. Chen H, Ryan P, Ferguson R, Yayaco A, Markowitz J,
Raksis K. Characteristics of acquired immunodeficiency
syndrome in older adults. J Am Geriatr Soc 1998; 46: 153–6.
5. El-Sadr W, Gettler J. Unrecognised human immunodeficiency
virus in the elderly. Arch Intern Med 1995; 155: 184–6.
Received 22 August 2002; accepted in revised form 12
December 2002