Medical Mystery Solved — The Devil Is in the Details | NEJM

Why It Matters

Recognizing HIV in older adults prevents missed diagnoses, reduces opportunistic infections, and guides timely treatment, ultimately improving survival and quality of care.

Key Takeaways

• Elderly weight loss and night sweats can mask underlying HIV infection.
• Nontyphoidal Salmonella bacteremia in seniors often signals immunodeficiency.
• Limited kidney biopsy specimens may obscure definitive glomerulonephritis diagnosis.
• Routine HIV screening should include patients over 65 with systemic symptoms.
• Incomplete antibiotic courses and continued exposure can cause recurrent infections.

Summary

The video walks through a diagnostic odyssey of a 75‑year‑old woman who presented with night sweats, an eight‑kilogram weight loss and new‑onset renal dysfunction. Initial work‑up focused on common causes in seniors—malignancy, vasculitis, infection—while HIV was not on the radar.

Laboratory studies revealed normocytic anemia, elevated ESR, rising creatinine and a nephrotic‑range proteinuria. Imaging showed no masses; a limited kidney biopsy suggested immune‑complex deposition consistent with membranoproliferative glomerulonephritis. After a brief course of prednisone, the patient developed Salmonella enteritidis bacteremia linked to undercooked eggs, highlighting steroid‑induced vulnerability.

Repeated infections, a pruritic violaceous rash, and a monoclonal T‑cell peak prompted further evaluation. HIV serology returned positive with a viral load of 156,000 copies/mL and CD4 count of 110, confirming AIDS. The case illustrates how older patients often omit sexual histories and how routine screening could have uncovered the infection earlier.

The lesson is clear: clinicians must keep HIV in the differential for unexplained systemic symptoms, regardless of age, and obtain comprehensive histories. Adequate tissue sampling, adherence to antimicrobial therapy, and early antiretroviral treatment can dramatically improve outcomes in this population.

Original Description

This Double Take video from the New England Journal of Medicine describes a woman who presents with night sweats and unintentional weight loss. The video explores the differential diagnosis of the patient’s presentation and how it evolves throughout the diagnostic evaluation and the patient’s clinical course.

For further reading, the following Clinical Problem-Solving article, referenced in this video, is available at the Journal’s website: The Devil Is in the Details (Ben-Chetrit et al., in the February 7, 2019, issue of the Journal, https://www.nejm.org/doi/full/10.1056/NEJMcps1808400 ).

Funding for this Double Take is provided by the Doris Duke Foundation, committed to building a creative, equitable, and sustainable future.

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The New England Journal of Medicine is the world’s leading general medical journal. Continuously published for over 200 years, the Journal publishes peer-reviewed research along with interactive clinical content for physicians, educators, and the global medical community at NEJM.org.