Severe Leg Pain in an HIV-Positive Man

Frank is a 55-year-old man who has been HIV positive for many years. He began antiretroviral therapy in 1996 with the combination of d4T + 3TC + nelfinavir and has been taking the same regimen since then with good adherence and minimal side effects. On treatment, his CD4 counts climbed from a nadir of 8 cells/mm³ to the 80- to 100-cells/mm³ range, and his viral load fell from 40,000 copies/ml to less than 400 copies/ml. His monthly visits to the HIV clinic generally focus on his other medical problems: COPD with bronchospasm exacerbated by a two-pack-per-day smoking habit, a deformed thoracic spine from an episode of a spinal osteomyelitis many years ago, a severe panic disorder for which he takes a variety of tranquilizers, and depression …