An AIDS patient asks for help

Paciente com AIDS pede socorro

IMAGES IN INFECTIOUS DISEASES IMAGENS EM DIP

An AIDS patient asks for help

Paciente com AIDS pede socorro

José Roberto Lambertucci

Curso de Graduação Ciências da Saúde, Infectologia e Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG

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A 21-year-old male patient with congenital human immunodeficiency virus (HIV) infection came to hospital complaining of fever, weight loss, diarrhea and abdominal pain which started three months earlier. He was the only son of a mother with Acquired immune deficiency syndrome (AIDS) who died two years after his delivery. He was raised by his grandparents and was being followed up at the outpatient clinic of our hospital. During adolescence he denied the disease, started using crack and cocaine, and frequently discontinued AIDS treatment (zidovudine, lamivudine and efavirenz). During clinical examination, he appeared ill, dehydrated, emaciated and complained of diffuse uncharacteristic abdominal pain (partially releaved with intravenous morphine). A tattoo on his forearm called the attention: socorro (help me in english -Figure A). He was hostile and manipulative. A colonoscopy with intestinal biopsy revealed the diagnosis of Mycobacterium avium complex infection. Ultrasound showed several intraabdominal lymph nodes and treatment with clarythromycin and ethambutol was started. Parenteral nutrition was also started and he improved slowly. The psychiatry consultant prescribed antidepressant and benzodiazepine agents. His mood varied greatly: occasionally he cooperated with the health personnel but, often, was agressive, and threathened to inject nurses and physicians with his blood. One day he fled the hospital. Four days later he returned to the emergence room in bad clinical condition. During the second admission he was given neuroleptic drugs and became more cooperative. He improved, was dismissed from hospital after request and died at home one month later. His grandmother confided to the physician that she was exausted and not willing to help him any longer. This patient seems to belong to a group of hateful patients classified by psychoanalysts as manipulative help-rejecters.

O paciente, de 21 anos, com infecção congênita pelo vírus da imunodeficiência humana (HIV) foi admitido ao hospital queixandose de febre, perda de peso, diarréia e dor abdominal de início havia três meses. Ele era filho único de mãe com síndrome da imunodeficiência adquirida (AIDS) que morrera dois anos após o seu nascimento. Os avós assumiram o compromisso de criá-lo e o acompanhavam ao controle periódico no ambulatório do nosso hospital. Durante a adolescência ele começara a negar a doença e fazer uso de drogas ilícitas (crack e cocaína) e havia relato de interrupção frequente do tratamento com antirretrovirais (zidovudina, lamivudina, efavirenz). Ao exame clínico ele aparentava estar doente, desidratado, emagrecido e queixava-se de dor abdominal difusa incaracterística (em uso contínuo de morfina com melhora parcial). Uma tatuagem no antebraço direito chamava a atenção: socorro (Figura A). Ele mostrou-se manipulador e hostil. A biópsia retal realizada durante colonoscopia revelou o diagnóstico de infecção pelo complexo Mycobacterium avium. O ultrassom do abdômen revelou a presença de inúmeros linfonodos intra-abdominais e ele foi tratado com claritromicina e etambutol. Iniciou-se também nutrição parenteral e houve melhora clínica progressiva. O psiquiatra sugeriu o uso de anti-depressivo e benzodiazepínico, com pouca melhora. O paciente tinha humor variável: ocasionalmente cooperava com os profissionais de saúde, mas, frequentemente, tornava-se agressivo e ameaçava infectar as enfermeiras e médicos usando seringa contendo o seu próprio sangue. Em momento de descontrole abandonou o hospital sem permissão. Quatro dias mais tarde foi re-admitido em precárias condições de saúde. Durante a segunda admissão, após o uso de neurolépticos, tornou-se mais cooperativo. Trinta dias após alta hospitalar, morreu em casa. A sua avó confidenciou ao médico que estava cansada de abrigá-lo e não mais se dispunha a dar-lhe a ajuda costumeira. Este paciente parece se enquadrar em um grupo de indivíduos classificados pelos psicanalistas como negadores de ajuda-manipuladores.

Received in 25/03/2012

Accepted in 26/03/2012

• 1. Groves JE. Taking care of the hateful patient. N Engl J Med 1978;298:883-887.
• 2. Lambertucci JR, Rayes AA, Nunes F, Landazuri-Palacios JE, Nobre V. Fever of undetermined origin in patients with the acquired immunodeficiency syndrome in Brazil: report on 55 cases. Rev Inst Med Trop Sao Paulo 1999;41:27-32.
• 3. Nobre V, Braga E, Rayes A, Serufo JC, Godoy P, Nunes N, et al. Opportunistic infections in patients with AIDS admitted to an university hospital of the Southeast of Brazil. Rev Inst Med Trop Sao Paulo 2003;45:69-74.

Publication Dates

• Publication in this collection
  24 Apr 2012
• Date of issue
  Apr 2012