A 29-yr-old man is admitted to hospital with a rash and high fevers....

A 29-yr-old man from Srilanka is admitted to hospital with a rash and high fevers. He gives a long history of pains in his hands and feet.
On Examination, he has an erythematous rash over his nose and cheeks.
ANA testing and dsDNA are strongly positive.
As part of his screening for pyrexia of unknown origin, an HIV antibody test is carried out, which proves positive.
His blood results are as follows:
Na, 136 mmol/l;
K, 3.7 mmol/l;
Urea, 3.5 mmol/l;,
Creatine, 67 U/l;
LFTs, normal;
Hb, 12.9 g/dl;
WCC, 2.4× 109/l (lymphocytes 0.8 × 109/l);
Platelets, 200 ×106/l;
ANA, positive;
dsDNA, positive;
CD4, 80 cells/mm3;
HIV antibody, positive;
Blood cultures, negative;
Syphilis serology, negative.

What is the most appropriate treatment  for his rash and arthropathy?
A. Combivir, efavirenz, co-trimoxazole
B. Prednisolone
C. Combivir, efavirenz, co-trimoxazole, prednisolone
D. Prednisolone, co-trimoxazole
E. Combivir, efavirenz

Answer:
D. Prednisolone, co-trimoxazole

Discussion: This Pt has acute SLE, and needs to be treated accordingly. The coexistence of HIV infection and SLE seems to be rare but a number of cases have been reported; the presence of
overlapping clinical and haematological features can make diagnosis difficult. Interestingly some case reports have observed the aggravation of SLE symptoms once HIV immunosuppression is
reversed with treatment. Since there is a chance that his HIV antibody test may be falsely positive, he
needs confirmation of his HIV status with proviral DNA and an RNA viral load prior to starting
anti-retroviral therapy. However the low CD4 count makes HIV immunosuppression very likely.
In any case, he is at significant risk of PCP and it would be prudent to put him on prophylaxis for
this with cotrimoxazole, especially as steroids are likely to further increase the risk of PCP.