Holoinspiratory Wheezing in a 46-Year-Old HIV-Seropositive Man

A46-year-old Italianman seropositiveforhumanimmunodefi-ciency virus (HIV) type 1 was admitted to our department witha 3-month history of nonproductive cough and progressivelyworsening dyspnea. The patient was a former heroin addictwith liver cirrhosis caused by hepatitis C virus and previouslytreated visceral leishmaniasis and latent syphilis. He was on an-tiretroviral treatment consisting of emtricitabine, tenofovir, andfosamprenavir with an undetectable HIV load and a CD4 T-lymphocyte count of 180 cells/µL. On hospital admission, thepatient was afebrile but short of breath at rest, with a heart rateof 110 beats per minute, respiratory rate of 35 breaths perminute, and oxygen saturation of 80% on room air. Physical ex-amination revealed holoinspiratory wheezing. His oral cavitywas unremarkable. Arterial blood gas showed an arterial pH of7.48, an oxygen partial pressure of 56 mm Hg, and a carbondioxide partial pressure of 28 mm Hg while breathing ambientair. A computed tomographic scan of the chest was performedshowing multiple bilateral pulmonary lesions,somewith acavi-tary appearance (Figure 1). Bronchoscopy demonstrated tra-cheal subocclusion caused by irregular, friable rosy vegetationsextending over 4 cartilaginous rings (Figure 1C). Biopsies wereobtained (Figure 2).What isyour diagnosis?