Question

A 38 year old HIV positive male presents for regularly-scheduled follow-up. He received pneumococcal and influenza vaccinations last year, and has had no opportunistic infections for several months. Current medications include efavirenz and nevirapine. Physical exam is unchanged from previous. Laboratory evaluation shows CD4+ lymphocyte count of 179/mm3. Tuberculin purified protein derivate (PPD) is placed intradermally, and is read 72 hours later as causing 4 mm of induration. Which of the following is the most appropriate next step in the management of this patient?

A. Chest x-ray
B. Clarithromycin
C. Trimethoprim-sulfamethoxazole
D. Fluconazole
E. Isoniazid, rifampin, and pyrizinamide

Answer 1

The next step for an HIV positive patient with a low CD4+ count and a 4 mm PPD induration is to get a chest x-ray to rule out active tuberculosis, even though the induration size is below the typical threshold for positivity in HIV-positive individuals.

Step-by-step explanation:

The most appropriate next step in the management of an HIV positive patient with a CD4+ lymphocyte count of 179/mm3 and a tuberculin skin test (PPD) resulting in 4 mm of induration is a chest x-ray. This is necessary to rule out active tuberculosis (TB), which is a significant risk in patients with low CD4+ counts and could present with a smaller induration than in patients with a normal immune response. Although the size of the induration is typically less than the 5 mm threshold considered positive in HIV-positive individuals, the patient's low CD4+ count and potential risk for TB necessitates further evaluation with a chest x-ray before considering prophylactic or therapeutic regimens.