Title : A case of late-stage HIV diagnosis despite multiple healthcare encounters
Abstract:
This case highlights a delayed HIV diagnosis in a 78-year-old female despite multiple clinical encounters over four years. The patient presented with multiple HIV indicator conditions, including unexplained weight loss, lymphadenopathy, and esophageal candidiasis. Due to demographic biases and lack of routine HIV screening in non-traditional populations, the diagnosis was missed until a late stage. This report emphasizes the importance of HIV testing in patients with persistent unexplained symptoms, regardless of demographic risk factors.
Introduction: HIV diagnosis in older adults remains a challenge, particularly in populations not traditionally considered high risk. This case demonstrates how failure to recognize HIV indicator conditions led to multiple investigations and delayed diagnosis. The case underlines the necessity of a broader approach to HIV testing, especially in patients with persistent, unexplained symptoms.
Case Presentation: A 78-year-old Caucasian female with a history of bilateral hip replacements was first seen in 2012 for routine follow-up. In 2016, she underwent a low-dose CT thorax as part of a lung health check, which revealed small pulmonary nodules. Over the next few years, she developed progressive lymphadenopathy, weight loss, dysphagia, and recurrent infections.
Between 2017 and 2021, the patient was evaluated over 20 times by multiple specialties, including respiratory, gastroenterology, breast services, and hematology. Imaging consistently showed progressive lymphadenopathy and stable pulmonary nodules. Multiple biopsies of lymph nodes demonstrated reactive changes but no malignant pathology.
In early 2020, worsening dysphagia and significant weight loss prompted further investigations, including esophageal endoscopy, which revealed candidiasis. Despite the presence of multiple HIV indicator conditions, an HIV test was not performed. It was only in 2021, after referral to the Infectious Diseases (ID) team, that an HIV test was conducted, revealing a CD4 count of 8 and a viral load of 346,000.
Discussion: This case underscores several key issues in delayed HIV diagnosis:
- Demographic Bias: The patient did not fit the traditional profile of an HIV-positive individual (elderly, heterosexual, Caucasian female), leading to a lack of consideration for HIV testing.
- Missed Indicator Conditions: Weight loss, lymphadenopathy, and esophageal candidiasis are well-recognized HIV indicator conditions that should prompt testing.
- Fragmented Care: The patient was seen by multiple specialties without a cohesive approach to her unexplained symptoms.
- Travel History: The patient had annual travel to Gambia, a country with a known HIV prevalence of 1.8% in 2020, which was not considered in earlier assessments.
Conclusion: This case highlights the need for increased awareness and routine HIV screening in patients presenting with persistent, unexplained symptoms. The implementation of
emergency department (ED) opt-out testing programs has successfully identified undiagnosed cases, but similar strategies should extend to specialist clinics and outpatient settings. Removing demographic biases and integrating HIV testing into routine assessments of lymphadenopathy and unexplained weight loss could lead to earlier diagnosis and improved patient outcomes.
