Miss Rachel Brown, a 45 year old woman originally from Ghana, is brought to hospital by her sister who is her next of kin. She has been behaving strangely for one week: she has not using her right arm while performing daily activities, and is now having difficulty walking. She has lost 10kg in weight over the last 6 months. She has hypertension, for which she takes amlodipine, and has had an anaphylactic reaction to penicillin in the past. Her father had a myocardial infarction aged 49. Rachel lives with her sister and is normally fully independent, working as a childminder. Rachel has never smoked, and drinks alcohol only very occasionally.
Her observations are:
- Temperature: 37.0 C, HR 98bpm, RR 20/min, GCS 14/15, BP 170/92mmHg, BM 5.2mmol/L, Sats 98% on air.
- A: airway clear
- B: air entry bilaterally, no crepitations or wheeze
- C: bounding pulse, warm peripheries, capillary refill < 2 seconds, heart sounds normal
- D: confused with slurred speech, GCS E4 V4 M6, AMT 1/10 (knows name) pupils equal and reactive. Right arm and leg shows increased tone, power 4/5 and brisk reflexes. Left arm and leg normal. Nystagmus and intention tremor on the left. Unable to cooperate with coordination and sensation
- E: abdomen soft, no masses, suprapubic tenderness, but no guarding or rebound, bowel sounds present
- Bloods: Hb 90g/L*, WCC 11 x109/L (neutrophils 8, lymphocytes 1), Platelets 90 x109/L, Sodium 141mmol/L, Potassium 3.9mmol/L, Urea 5.7mmol/L, Creatinine 95µmol/L, Albumin 40g/L, ALT 22IU/L, AST 35IU/L, ALP 45IU/L, Bilirubin 14µmol/L, CRP 66
- CXR: no focal consolidation
- Urine dip: protein +, blood +, leucocytes -, nitrites –
- CT head without contrast: non-specific white matter changes in the left cerebral hemisphere
- MRI brain: white matter changes: multifocal, asymmetric periventricular and subcortical involvement, with no mass effect
Question: How should we proceed to test her for HIV?
Question setters: Dr. Nadia Ahmed and Dr. Emily Chung, HIV and sexual health specialist registrars, Mortimer Market Centre, Central and North West London Foundation Trust
Expert: Dr. Simon Edwards, HIV consultant physician, Mortimer Market Centre, Central and North West London Foundation Trust
*some hospitals are still using g/dL as units for Haemoglobin in which case the result would be 9.0 g/dL