I wanted to discuss a patient who walked into my office today at 5:00 pm. 32 year old Native female complaining of recurrent oral thrush for one year. She was treated with nystatin by 3 different physicians.   Was seen in emergency yesterday for left lower quadrant pain and diarrhea for 1 week. Also had mild vaginal bleeding.

LAB: Bhcg neg hgb 95 wbc 3.87 neut %73.5 lymp%15.8 platelet 250 mcv 63.4 smear microcitic,anisocytosis polychromasia hypochromia and basophillic stippling, all lytes normal except K+ 3.1

Past medical Hx.- VSD repaired at age 16, I.V. drug use at age 18, Caesarean deliver 1995
Herpes zoster during pregnancy, Medication Nil

What investigations and differentials?
(Reply 1- M. Parmar) The patient described above has following problems:
1. Microcytic, hypochromic anemia
2. History of Intravenous Drug use and previous VSD repair (?Blood Transfusion)
3. Recurrent oral Thursh : Candidiasis
4. Abd. pain and diarrhea.
5. history of Zoster.
She has symptoms and features of immunosuppression and with the history given HIV infection will be high on the list.
I will request HIV test, anemia work-up mainly serum ferritin, GI investigations to confirm is it oral thrush or viral lesions and if there is esophageal involment. Stool cultures, Ova & Parasites and flexible sigmoidoscopy.   Let's here other's opinions.
(Reply 2- N. Woods) What did you find on physical exam? Any lymphadenopathy? If not already done I would check her glucose level and certainly with risk factor of IV drug abuse (there is no mention of sexual risk factors) one needs to check her HIV status. She also appears to have an anemia and this should be investigated further ferritin and possibly bone marrow. The white count is low but I was expecting it to be lower (I don't know why).
(Reply 3- A. de la Rocha) With the history of previous VSD repair, likely with the use pf a synthetic patch, there is a strong possibility of subacute bacterial endocarditis.  Does she have a murmur? Does she have any clinical evidence of SBE? I'd get an echo and repeat blood cultures.
(Reply 4- A. de la Rocha) Likely she has SBE. Do blood cultures and get an echo. Does she have any murumur suggestive of VSD patch disruption or other manifestations or SBE.  Watch for acute aortic insufficiency since the typical membanous VSD repair is just under the non-coronary cusp of the aortic valve
(Reply 5- S. Kaczmarek) I would agree with Nancy's approach.  Re history - is her vag bleeding menstrual or not, if abnormal how long has it been going on? Although she may not have done IV drugs for some years - have any more recent sexual partners been IDUs? Re physical exam - did she have visible candidal throat infection? Was a pelvic done - if so - any vaginal candidiasis/visible source for her bleeding/masses?
(Reply 6- G. Adesanya) Additional clinical information on patient:
1. greenish rhinorrhea for 2 months.
2. aphthous oral ulcerations
3. gastroesophageal reflux symptoms
4. No recurrent history of infections
5. weight loss index proportional to decreased caloric intake
6. both parents were treated for active TB
Findings at gastroscopy:
1. oral candidiasis
2. grade 3 relux esophagitis: non-confluent distal esophageal ulcers
3. deep, linear circumferential ulcers affecting the whole esophagus
4. minimal antral gastritis.
Histological and mycological studies pending
Urinalysis:
- 4+ blood
- 40 - 100 wbc/hpf
- many yeast organisms.
(Reply 7- by Authors) Update on case of 32 y.o female with recurrent oral thrush
Physical exam did not reveal any significant lymphadenopathy or splenomegally. Oral thrush was present. She did not have a murmur. She did have a 35 lb weight loss over the past year. There was also some
shady sexual contacts around the time she did I.V. drugs.
New laboratory results - albumin 32 down, total protein 71 n IgA 4.0 n, alkp 126 up IgG 19.4 up, ast 44 up IgM 1.8 n, alt 31 n ,ld 188 n, ggt 63 up, globulin 39 up, Echocardiogram pending
Abdo U.S. showed only fatty liver and gallstones, sinus views (some sinus pain and congestion) mild mucosal thickening of the right sinus, Gastroscopy showed severe esophageal ulceration throught the whole
length of the esophagus with grade 3 reflux esophagitis (not felt to be sole responsability of the reflux) --biopsies pending
Colonoscopy showed ileocecal ulcers and terminal ileum enteritis --biopsies also pending
The answer to the question on everyones mind Yes her HIV test (elisa) was highly positive. The result of the
confirmatory test will be available friday. So I am now treating my first AIDS patient and help or suggestion are welcome .
(Reply 8- S. Kaczmarek) This case is very interesting to me for a number of reasons - it is the second report I've gotten in as many days of a positive test.  I've been concerned for some time that IDU is going to be a major factor in HIV infection in our area in the future.This is of course the case in many other jurisdictions In recent months I've been meeting with agencies in the addictions /detox field. Their internal data suggests that significant numbers of their clients have a history of IV drug use.  For example the some centres in the district involved in detox report a 25% self report of current or previous IDU. Do you think IV drug use or sex with a user - is the cause in this case?   As for help - Pauline Gauthier works in our HIV program at the health unit - she tells me the Haven program in Sudbury are very helpful 9 1 800 410 1814. Also suggest you look at the CATIE internet site - the Community AIDS Treatment Information Exchange. thjis is a Ministry funded program offering the lates information on treatment , services, clinical trials, other resources to patients and physicians. Their online service offers access apparently to much of their information as well as electronic discussion groups for both patients and providers.
(Reply 9- by Authors) Thanks for all the imput regarding my HIV case. Her blot confirmatory test came back positive friday at 3.00p. I then had to admit the patient to the MHU. She isn't coping well with the news and is having difficulty finding support. Most 1-800 numbers are closed on weekends.  We now await the result of her husband's test as well as her 2 y.o. daughter.  I will definately be ordering the CD4 count and the viral load as soon as possible. I am waiting to confer about the antiviral therapy. I don't feel comfortable starting it on my own till I understand what needs to be followed and possible side effects. As far as the anemia, it was a hypochromic microcitic. Ferritin was low normal at 34. If may just be anemia of chronic disease. B12 and Folate were normal.  As far as recurrent oral thrush in an otherwise healthy adult I definately would not let it drop till another risk factor was found. This would include diabetes, steroid puffer use or other reasons for
immunosuppression. A good history directed at HIV is very important. Routine blood work including a CBC, BS would be a good place to start.  Thanks I let you know any more updates that are interresting.
(Reply 10- M. Parmar) Now, management points:
1. We should get CD4 cell count to assess the degree of immunosuppression.
2. She will need antiretroviral therapy, likely triple therapy. I will let you know the names and dosage later.
3. Don't forget PCP prophylaxis and if she has symptoms of cough, fever or shortness of breath consider
bronchoscopy to evaluate the possibility of PCP. I think it is less likely at present as LD is normal.
4. What about her anemia work-up.
(Reply 11- D. Reich) CD4 counts are now not as important as the viral load count, ie the RNA load in the serum. Has this already been done?
(Reply 12- D. Arnold) As I sit here pondering this unfotunate series of events, my mind wonders why she was treated for oral thrush THREE times. For those who are Primary Care Physicians, how should this patient have been treated differently?  Should other tests be done on the first presentation of oral thrush in an adult, if so what? What could the prognosis have been changed if her HIV status had been found out one year ago? (Lynne and Rick can confirm this, but my understanding is that she saw several other physicians over the course of the year and this was her visit in eighteen months to their office.)