Failure to Diagnose a Life-Threatening Infectious Disease

Case Summary:

This case involves a 40-year-old in male a monogamous long-term relationship with his husband. In late 2015, he sought primary care for myalgia, skin rashes, and sore throats. Over the next five years, he visited his primary doctor frequently with complaints of depression and anxiety, skin rashes, stomach pains, headaches, and herpes breakouts. In four years under his primary's care, he complained of diarrhea, fatigue, and persistent yeast infections. The patient was tested for hepatitis and various lab tests, but not HIV. HIV testing was eventually conducted in 2020, and he was diagnosed as positive. He began treatment for HIV at a different clinic and was subsequently diagnosed with Kaposi's sarcoma in addition to full-blown AIDS, and treatment with Biktarvy ® was initiated.

Case theory:

The human immunodeficiency virus, or HIV, causes the body to attack its own immune system. Since HIV is a retrovirus rather than a DNA virus, it copies its RNA onto the host cell's DNA, changing its genome in the process. There is no cure for retroviruses, but they can be managed.

Symptoms of HIV include fevers, aches and pains, fatigue, and unintentional weight loss, as well as skin rashes and swelling of the lymph nodes. An HIV diagnosis should be ruled out if a patient reports these symptoms. Several symptoms in this case should have alerted the physician to test for HIV. The HIV virus causes skin rashes in people who have the virus. It is common for HIV-positive people to develop a rash at some point. Infection may begin with this common symptom.

The probability of contracting HIV during intercourse is greater for those who have genital herpes sores. The immune system tries to heal a sore by directing many immune cells to the wound. The HIV virus then infects those cells. HIV in semen is highly infectious if it comes into contact with a herpes sore. In addition, candidiasis (yeast infections) affecting the mucous membranes of the body is a common opportunistic infection in people living with HIV. The risk of developing candidiasis is higher for people with HIV.

The average life expectancy for people with HIV without treatment is 10 years. Patients can often live decades after their diagnosis with treatment, as the progression of cancer can be slowed, and the disease can be controlled. Failure to diagnose HIV may constitute medical malpractice. As a result of not testing for HIV in this case, the patient's prognosis was reduced and the disease advanced.

Questions for expert:

1. What is the frequency at which you evaluate and manage patients who are at high risk of HIV infection?
2. What were the relevant criteria to be used prior to 2019 to determine whether a patient should be screened for HIV?
3. In HIV cases, how does the timeliness of diagnosis and intervention affect patient outcomes?
4. Are you available to review 150 pages of medical records and provide a verbal opinion?

Expert response:

We are routinely involved in the care and treatment of all HIV+ patients, and we encourage yearly screening of all patients at risk of HIV. Any MSM should be screened for HIV regularly. The earlier the diagnosis of HIV is established the better the patient will be in terms of reversing any effects of the virus and reconstituting the immune system. In this case, the patient was positive for HIV for approximately a decade before finally being tested. He would not have developed KS or other AIDS-defining illnesses.