Hilda was a 55-year-old Hispanic woman with advanced AIDS when she
presented in April 2003, noting 1 week of word-finding difficulty. She
was well known to the clinic for her multiple psychiatric admissions,
her substance abuse, and her nonadherence to medications. Hilda's HIV
infection was diagnosed in 1995, and she had a long history of bipolar
disease and schizoaffective disorder. Her medical history included
mild type 2 diabetes, syphilis, and chronic low back pain with mild
degenerative joint disease evident on MRI. She was a heavy smoker and
frequently used benzodiazepines or painkillers that she bought on the
street. She had recurrent oral candidiasis that responded to
fluconazole. At this presentation, she was again admitted to the
hospital.

When Hilda first presented in 2000, her CD4+ cell count was 42/µL. She
did not want to take antiretroviral drugs and took prophylactic
medication for Pneumocystis carinii pneumonia only sporadically. In
late 2001, she was on an efavirenz-based regimen for 2 months but
discontinued it because of abdominal pain. During that brief time
while she was receiving medication, Hilda's viral load had become
undetectable and her CD4+ cell count had risen to 97/µL. Following a
psychiatric admission in March 2002, she was switched to a
lopinavir-based regimen but took this medication only occasionally.

At the time of the present admission for word-finding difficulty 1
year later, her CD4+ cell count was 13/µL and her viral load was
121,000 copies/mL. Examination revealed disorientation to time, some
difficulty in naming random objects, and a diastolic murmur. A CT scan
of the head demonstrated 3 ring-enhancing lesions. Her serum
Toxoplasma IgG titer was negative. A chest radiographic examination
was negative. Echocardiographic examination revealed aortic valve
calcification and severe aortic regurgitation. Single-photon emission
CT images with thallium revealed 2 foci of increased activity in the
left parieto-occipital region consistent with a malignant process.

A consultant from radiation oncology requested that a lumbar puncture
and brain biopsy be performed before treating empirically for CNS
lymphoma. Despite Hilda's extensive psychiatric history, it was
believed that she had the capacity to refuse these procedures, which
she did. During her hospital stay, her word-finding difficulty became
more pronounced and her mood more depressed. The addition of
corticosteroids to her regimen yielded clinical improvement.

Advanced directives were discussed with Hilda; she requested that no
resuscitation or intubation be performed should the need arise. A
do-not-resuscitate order was placed in her chart. Hilda's major
pleasure in the hospital was being allowed to go outdoors to smoke
cigarettes. Preparations were begun for transfer to either a skilled
nursing or a hospice facility. Before they could be completed, Hilda's
condition began to destabilize, with progressively worsening renal
function and development of bilateral pneumonia. Despite antibiotics
and fluids, Hilda's condition deteriorated, and she died 7 weeks after
admission.

An autopsy revealed a 1.8-cm poorly differentiated adenocarcinoma in
the right upper lobe, associated with scarring and necrosis. Two
metastatic lesions were found in the brain; these lesions were
pathologically identical to the lung lesion. A right parietal
hemorrhagic lesion was also noted. Enterococcus faecalis grew from the
lung tissue as well.