HPIA previously healthy 33 year old male

complaining of progressive nonproductive cough for 2 months. He became more short of breath with exertion in the last week, and states that he has lost 10 lbs in the last 4 months despite having a good appetite. He has had chills mostly at night for about the same period.

ROS: Denies wheezing, flu-like sxs, diarrhea, odynophagia, LE edema, PND or orthopnea.

HPI continuedAllergies: NKDAPast Medical Hx: nonePast surgical Hx: appendectomy

at age of 13.Family Hx: mother: HTNSocial Hx: construction worker.

No tobacco, ethanol or illicit drug use. Sexually active with women. 10 Sexual partners in lifetime. No hx of STIs.

Physical ExamVitals: T 38.5, BP 115/65, HR: 101, RR 22, Osat

90%General: In some distress. Acyanotic, alert and

oriented x3HEENT: normocephalic, TM clear bilaterally,

PEERLA, EOMI, no oral thrush or ulcerations. + cervical nontender lymphadenopathy bilaterally.

Neck: Supple, no JVD. No carotid bruits. Chest: RRR, normal s1 s2, no murmurs, rubs or

gallops. Extremities: No LE edema, no clubbing, no

rashes.

What is your differential diagnosis?

Differential Dx:Pneumonia Lung abcessCHFCOPDPleuritisCostocondritisCongenital Heart Disease

Laboratory and ImagingCBC : WBC decreasedBMP: normalInduced sputum stain and culture:

pendingCXR: pending

HIV work upCD4 count: 120 cells/mm3Rapid HIV test: positive

Imaging

1.PA view. Normal Chest Radiograph

2. Diffuse ground glass opacification without air bronchograms and without obliteration of the pulmonary vessels.

Induced Sputum

Methenamine silver stain. Ovoid, to cup-shaped organisms with focal thickening of the cell wall Pneumocystis jiroveci

Giemsa stain. Foamy alveolar exudate

What is Pneumocystis jiroveccii pneumonia?Classic clinical presentation:

insidious onset of cough ( +/- sputum production), dyspnea and fever.

Other symptoms include fatigue, chills, chest pain, and weight loss.

Epidemiology: affects immunocompromised individuals. It is the most common outpatient infection in HIV+ individuals ( 90% of patients have a CD4 count <200 cells/mm3)

Physical Exam findingsTachypneaHypoxemiaFever >38.5Pulmonary symptoms: Crackles

and rhonchi, but 50% of examinations can be normal.

Extrapulmonary symptoms: lesions in the liver, spleen ( hepatosplenomegaly) kidney and brain.

DiagnosisIdentify the organism: - Induced sputum - Bronchoalveolar lavage if

sputum negative. - P. jirovecci identified via

methenamine silver or Giemsa stain.

- Immunofluorescent staining. Most sensitive.

TreatmentTMP-SMX for 21 days is the

preferred treatment for P. jirovecci pneumonia.

Prophylaxis with TMP-SMX : start in all HIV patients with CD4 count is <200 cells/mm3.