hpi a previously healthy 33 year old male complaining of progressive nonproductive cough for 2...
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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.