Case presentation
51 years old gentlemen with no previous medical history, presented with
twenty days history of productive cough of yellowish sputum but
sometimes mixed with minimal blood streaks. He also reported nocturnal
fever, progressive shortness of breath accompanied with generalized
fatigability, and significant unintentional weight loos about 15 Kg,
with loss of appetite. He denies any other symptoms. He denies any
history of IV drug use, tattoos. Works as a construction worker, married
but he admitted to have a few extra-marital sexual relationships.
On admission he was febrile with temperature 38.9 but other vitals were
within normal limits. On examination patient was cachectic and pale.
neck examination was unremarkable. Chest examinations showed reduced air
entery on right lower lung zone with coarse crackles and dullness
percussion note. The rest of physical examination were completely
unremarkable.
His lab on admission showed bicytopenia (anemia and thrombocytopenia)
with Hb 8.5 mg/dL and platelets 127 x10^3/uL. later on, he developed
pancytopenia with WBC reaching 1.9 x10^3/uL (absolute neutrophilic
count 1.5 x10^3/uL and lymphopenia 0.3 x10^3/uL). liver function
test, renal function test, were both normal. Peripheral smear showed
normocytic normochromic anemia with thrombocytopenia and lymphopenia
with few reactive lymphocytes. Blood test for HIV came back positive and
accordingly other tests were sent. Sputum smear for Acid fast bacilli,
and PCR came negative for TB but two weeks later his sputum culture came
positive for mycobacterium other than tuberculosis, and at the same time
his Quantiferon test was indeterminate. He underwent bronchoscopy with
bronchoalveolar lavage (BAL) and two weeks later the BAL culture result
came positive for mycobacterium other than TB, and pneumocystis jiroveci
was detected, as well as candida albicans. Both CMV and EBV PCR were
positive from BAL. Furthermore, two bottles of blood culture showed
cryptococcus neoformans growth. His rapid plasma reagin (RPR) screening
for syphilis was positive, confirmatory test with Treponema pallidum
antibodies was reactive as well. Urine test for chlamydia trachomatis
and Neisseria gonorrhoeae DNA both were negative.
Chest x-ray showed small patchy areas of airspace shadowing in the right
lung base and to a lesser extent in the right infra clavicular region
(Figure A). Computed tomography scan (CT) of the neck showed bilateral
cervical and supraclavicular enhancing lymph nodes, some of which
demonstrate central non-enhancing areas likely representing necrosis.
The largest lymph nodes are seen at level 2A bilaterally measuring 8 mm
in short axis dimension (Figure D). CT chest showed right lung ground
glass nodular infiltration at posterior segment of upper lobe and apical
segment of lower lobe, postero-basal collapsed consolidation. The left
lung shows few nodular opacity 6x4 mm at lung apex, postero-basal
atelectatic changes. mediastinal lymph nodes are noted largest at
preaortic space measures 15x11.5 mm (Figure B and C). Infectious disease
department (ID) and center of communicable disease (CDC) were notified
according to our hospital policy and the Patient started on appropriate
treatment including trimethoprime-sulfamethoxazole and steroid. The
patient was discharge after the screening of other sexual transmitted
disease and CD4 count were send and to follow the result at the clinic,
and then to start anti-retroviral therapy (ART) accordingly.
Unfortunately, later on after several days his blood cultures turn to be
positive for cryptococcus neoformans, at that time the patient went back
to his home country. Two weeks later his sputum and BAL cultures came
positive for mycobacterium other than tuberculosis.