Photo Quiz

Hypoxemia and Nonproductive Cough

 

Am Fam Physician. 2017 Jul 15;96(2):121-122.

A 47-year-old man presented with general fatigue, chills, dyspnea, dry cough, and occasional subjective fever that began two months earlier. He had an unprovoked deep venous thrombosis about one year before presentation that was treated with rivaroxaban (Xarelto) for six months. His medical history was also notable for spinal stenosis and gastroesophageal reflux. He was not taking any medications. He had no history of smoking or substance abuse. He quit chewing tobacco and drinking alcohol one year before presentation. He was divorced and sexually active.

He had a regular pulse of 122 beats per minute, unlabored respirations at 21 breaths per minute, oxygen saturation of 78% on room air, and a body temperature of 100.8°F (38.2°C). Physical examination revealed a new oily and scaly erythematous rash on his forehead, nose, and cheeks. Pulmonary examination showed good air movement but diffuse rales bilaterally. Arterial blood gas measurements showed partial pressure of oxygen was 50 mm Hg and partial pressure of carbon dioxide was 26 mm Hg. Other laboratory testing showed a white blood cell count of 11,000 per μL (11.0 × 109 per L) and hemoglobin level of 11 g per dL (110 g per L).

Chest radiography demonstrated diffuse hazy opacities (Figures 1 and 2). A high-resolution computed tomography (CT) scan of the chest also showed diffuse opacities, some with haziness or ground-glass appearance. Limited bedside echocardiography showed no evidence of left ventricular dysfunction or right ventricular strain.

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Figure 1.


Figure 1.

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Figure 2.


Figure 2.

Question

Based on the patient's history, physical examination, and other findings, which one of the following is the most likely diagnosis?

A. Miliary tuberculosis with pulmonary involvement.

B. Mycoplasma (atypical) pneumonia

C. Pneumocystis jiroveci pneumonia.

D. Pulmonary embolism.

Discussion

The answer is C: Pneumocystis jiroveci pneumonia, previously known as Pneumocystis carinii pneumonia. It is the second most common AIDS-defining opportunistic infection after esophageal candidiasis.1 It is an atypical fungal infection that is uncommon in patients without human immunodeficiency virus (HIV) infection. Bronchoscopic lavage and biopsy confirmed the diagnosis, with a methenamine silver stain highlighting the fungal cyst walls. An HIV antibody test was positive.

Address correspondence to Matthew S. Rice, MD, at mobilematthew@icloud.com. Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Buchacz K, Baker RK, Palella FJ Jr, et al. AIDS-defining opportunistic illnesses in US patients, 1994–2007: a cohort study. AIDS. 2010;24(10):1549–1559....

2. Huang L, Cattamanchi A, Davis JL, et al. HIV-associated pneumocystis pneumonia. Proc Am Thorac Soc. 2011;8(3):294–300.

3. Eisenstat BA, Wormser GP. Seborrheic dermatitis and butterfly rash in AIDS. N Engl J Med. 1984;311(3):189.

4. Kaplan JE, Benson C, Holmes KK, Brooks JT, Pau A, Masur H. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep. 2009;58(RR-4):1–207.

5. Sharma SK, Mohan A, Sharma A, Mitra DK. Miliary tuberculosis: new insights into an old disease. Lancet Infect Dis. 2005;5(7):415–430.

6. Reittner P, Muller NL, Heyneman L, et al. Mycoplasma pneumoniae pneumonia: radiographic and high-resolution CT features in 28 patients. AJR Am J Roentgenol. 2000;174(1):37–41.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Assistant Medical Editor.

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