A traveler with hypothermia: Twist in the taleMP Cariappa
Department of Community Medicine, AFMC, Pune, Maharashtra, India
Doctors in military service are exposed to patients having myriad clinical presentations in routine. The relevance of eliciting thorough histories and conducting a proper general examination in cases where the etiology is suspect, is an art that needs to be encouraged especially, amongst the doctors in the peripheries of the medical echelons.  A seemingly straightforward case of hypothermia managed at a medical facility, in a remote region of the Himalayas, turned out to be far more complicated than first evident.
A 32-year-old traveler was evacuated by a doctor to the nearest health-care center, as a case of altered behavior with low body temperature, on a wintry morning in January (ambient temperature −15°C). The history as noted at the first point of contact outlined a loss of appetite for a few days with a day old history of fever along with generalized weakness and a dry cough. On arrival at the medical center, the patient was delirious and no further history could be elicited.
The patient was found to be emaciated with a weight of 45 kg, and evident muscle wasting concealed under heavy winter clothing. Rectal temperature 95°F, weak pulse of 50/min, BP - 100/24 mm Hg, shallow RR - 18/min, SpO 2 84% with scattered crepitations across the upper lung fields. Generalized lymphadenopathy, with non suppurative and matted inguinal lymph nodes was noted. On attempting urinary catheterization, there was profuse bleeding leading to a suspicion of urinary stricture.
The patient was non-cooperative and had a prone semi flexed position. He was agitated with incoherent speech. Glasgow Coma scale score was 11/15. Pupils were normal sized but sluggish in reaction, with photophobia. Babinski's sign was extensor bilaterally. Deep tendon reflexes were normal, and there were no signs of meningeal irritation.
Hemoglobin 12.4 g %, Total Leukocyte Count 10,400 cu.mm, Urea 37 mg%, Creatinine 1.2 mg % Blood Sugar 62 mg %. Urine Routine/Microscopic Exam - acidic, albumin++, sugar+, numerous RBC/HPF, 4-5 pus cells/HPF. Human immunodeficiency virus (HIV) testing by Tridot method was positive for HIV-1 and subsequently was confirmed by Western Blot (done postmortem).
Due to his moribund condition it was possible to obtain only a supine anteroposterior view of the chest. The resultant image was of poor quality; the image was photographed [Figure 1] and then reported on, through telemedicine facilities, as having multiple patchy opacities in both the lung fields, which were predominantly perihilar in distribution. Ruling out high altitude pulmonary edema by the history obtained from fellow workers, of having been in the sector for more than 6 months and keeping in view his immune status, Kaposi's Sarcoma was to be considered among the non-infective etiologies, as per expert opinion.
The treatment instituted aimed at rewarming the patient. Warm intravenous fluids and antibiotics were commenced and oxygen was given by mask. Subsequently vital parameters deteriorated with sudden collapse and despite vigorous resuscitation efforts, the patient could not be revived.
Primary accidental hypothermia is a result of direct exposure of a previously healthy individual to the cold. Mortality is much higher for those patients who develop secondary hypothermia as a complication of a serious systemic disorder. Physical examination findings can also be altered by hypothermia and patients may be confused or combative. Dementia and psychiatric illnesses compound the problem by impeding adoption of adequate preventive measures to prevent hypothermia. 
Oral or axillary temperature measurements may not reveal the true picture and thus it is essential that in cold areas, rectal thermometers be available at all medical facilities. The initial presentation of our case would have led the doctors astray in establishing a diagnosis, if only the presenting symptoms were addressed.
The presence of inguinal lymphadenopathy and the possible urethral stricture along with the gross emaciation of the patient, led to a suspicion of an underlying Sexually Transmitted Infection with HIV. Accordingly testing was requested, and all personnel involved in the treatment were advised to strictly adhere to Universal Safety Precautions.
The clinical consequences of HIV infection encompass a spectrum ranging from an acute syndrome associated with primary infection to a prolonged asymptomatic state to advanced disease. Pulmonary disease is one of the most frequent complications of HIV infection, with the most common manifestation being pneumonia. 
When the laboratory test for HIV came in positive, the entire clinical profile fit the picture of a HIV infection, having its effect on the psyche, possibly HIV dementia, accounting for the abnormal behavior and preceding lack of dietary intake with personal neglect. The hypothermia could possibly be accounted for by the lowered immune status and the lack of intake of adequate calories in the immediate preceding days precipitated by the ambient subzero temperatures.
The dismissal in routine, of the present case, as one of hypothermia would not have revealed the underlying pathology were it not for the sudden deterioration of the patient. Thus, the need for doctors to be vigilant for hidden signs of underlying disease keeping in view environmental parameters also, is brought out here.