HIV with poorly controlled diabetes

Correct answer: D. The HbA1c of 10%

• A. A platelet count of 210,000 sits comfortably in the normal 150,000 to 450,000 range and poses no bleeding risk.
• B. An undetectable viral load is the treatment GOAL, indicating effective antiretroviral therapy and minimal transmission risk. It is reassuring, not concerning.
• C. A CD4 count of 460 is close to the normal range of 500 to 1500 and well above the threshold of 200 that defines significant immunosuppression. This patient's HIV is doing considerably better than his diabetes.
• D. CORRECT. An HbA1c of 10 percent corresponds to an average blood glucose around 240 mg/dL and represents SEVERELY UNCONTROLLED diabetes. The dental consequences are immediate and concrete: impaired neutrophil function and microvascular disease mean higher infection risk and delayed healing, worse periodontal response, and a real risk of intra-operative hyperglycaemic or hypoglycaemic events. Elective surgery is deferred pending medical optimisation — generally an HbA1c under 7 to 8 percent.

Note: The teaching point of this item is that a well-controlled chronic infection is less dangerous than a badly controlled metabolic disease. Do not be distracted by the HIV label.

Correct answer: D. Glycaemic status over the preceding six months

• A. No fasting is required, which is one of the practical advantages of HbA1c over a fasting plasma glucose.
• B. Two to three months is exactly right — this is the standard description of what the test represents.
• C. An HbA1c of 6.5 percent or above on two occasions is a recognised ADA diagnostic threshold for diabetes; 5.7 to 6.4 percent defines prediabetes.
• D. CORRECT as the exception. HbA1c reflects roughly the preceding TWO TO THREE MONTHS, not six. The window is set by the 120-day lifespan of the red blood cell, and because more recent glucose exposure weights the result more heavily, the last month contributes about half the value.

Note: HbA1c becomes unreliable where red cell turnover is abnormal — haemolytic anaemia and recent transfusion falsely LOWER it, iron deficiency and asplenia falsely RAISE it, and haemoglobinopathies interfere with the assay.

Correct answer: B. Asthma

• A. HIV itself contributes through chronic immune activation and inflammatory cytokines, which promote insulin resistance.
• B. CORRECT as the exception. Asthma as a disease has no direct effect on glucose metabolism. The qualifier worth knowing is that SYSTEMIC corticosteroids used for an asthma exacerbation certainly do cause hyperglycaemia — but this patient uses only an as-needed inhaler, and inhaled corticosteroids at standard doses have negligible systemic glycaemic effect.
• C. Antiretroviral therapy is a well-documented contributor. Older protease inhibitors and certain nucleoside reverse transcriptase inhibitors cause lipodystrophy, dyslipidaemia and insulin resistance.
• D. Any acute infection raises cortisol and catecholamines, which oppose insulin and drive glucose up. This is exactly why an untreated dental abscess and poor glycaemic control aggravate one another.

Note: The relationship between periodontitis and diabetes runs in both directions: each worsens the other, and periodontal treatment produces a measurable improvement in HbA1c.