A 35-Year-Old Immunocompromised Man With Cough of Three Weeks Duration

A 35-year-old man with advanced human immunodeficiency virus (HIV) infection presented to the emergency department with a chief complaint of cough for three weeks. His cough was productive of clear sputum, and he also reported progressively worsening shortness of breath. He had subjective fevers and chills, fatigue, and 25-pound weight loss in the few weeks prior to presentation. He denied any hemoptysis, chest pain, and sick contacts. The remainder of the review of systems was negative. The patient had advanced HIV infection, with a CD4 count of 5 cells/mm3, which was diagnosed approximately one year prior. He had not sought care for his HIV infection since that time. He also had a history of ventricular septal defect for which he had undergone surgical repair with VSD patch as a newborn in 1975. The patient worked as a welder and was not taking any prescription medications at the time of presentation. He denied the use of tobacco and illicit drugs. He stated that he formerly abused alcohol, i.e., approximately three pints of liquor daily, but quit three months prior to presentation. Upon physical examination, the patient’s temperature was 103.5° Fahrenheit, heart rate of 121 beats/minute, blood pressure of 153/87 mm Hg, respiratory rate of 20/min, and oxygen saturation of 94% on ambient air. He weighed 134 pounds and his body mass index was 22. He appeared well nourished, in no apparent distress, and was able to speak in full sentences. Cardiovascular exam revealed tachycardia and a systolic ejection murmur, which was loudest at the left upper sternal border. Auscultation of his lungs revealed diffuse inspiratory and expiratory wheezing bilaterally. A posteroanterior chest radiograph (Figure 1) and a coronal reformatted image from a computed tomogram (CT) of the chest without contrast (Figure 2) showed diffuse, symmetric, ground glass opacities with relative peripheral sparing, typical of Pneumocystis pneumonia (PCP). Upon admission, arterial blood gas (ABG) on 28% fraction of inspired oxygen (FiO2) revealed a pH of 7.48, pCO2 of 38 mm Hg, pO2 of 69 mm Hg, and bicarbonate of 28 mmol/L. His alveolar-arterial gradient (A-a gradient) was 60 torr. He was treated with trimethoprim-sulfamethoxazole and prednisone for suspected PCP. A bronchoalveolar lavage (BAL) was performed. Silver stain of the BAL specimen A 35-Year-Old Immunocompromised Man With Cough of Three Weeks Duration