Fever, Weight Loss, Cough, and Chest Pain in a HIV-Positive Man

Asim Diab, MD, PhD; Rita Gander, PhD; Debra Grant, MT(ASCP)SM; Dominick Cavuoti, DO; Paul Southern, MD

Disclosures

Lab Med. 2005;36(11):696-699. 

In This Article

Abstract

36-year-old African-American homosexual man.

Shortness of breath, left-sided chest pain that was worse when lying flat, fever, productive cough, generalized muscle weakness, and a 12-pound weight loss.

The patient had been admitted previously for ongoing productive cough and fevers and 1 month prior to this most recent admission to our hospital, the patient had been admitted to another hospital where he underwent a bronchoscopy and tuberculosis and Pneumocystis carinii (PCP) pneumonia were ruled out. However, 1 day after discharge from the hospital, the patient presented at our hospital because his symptoms had worsened. He was treated with primaquine and clindamycin for presumed PCP infection. Although his sputum smears were negative for PCP by direct fluorescence assay (DFA), he remained symptomatic. Subsequently, the patient presented on this admission with fever and left-sided chest pain that was worse when lying flat.

Seven years ago, he had been diagnosed with human immunodeficiency virus (HIV) infection and had taken anti-retroviral drugs only intermittently after receiving this diagnosis. In addition, he had a previous history of histoplasmosis with duodenitis, anal condyloma, and a parvovirus ± 9 viral infection which led to anemia that required frequent blood transfusions.

Cephalosporins.

Half-pack a day smoker; occasional ethanol and marijuana use.

The patient's vital signs were: temperature, 38.1°C; blood pressure, 128/74 mmHg; and heart rate, 110 beats per minute. He was cachectic and in mild distress. A head-ear-eyes-nose-throat (HEENT) exam showed slight bitemporal wasting, some shotty lymphadenopathy, and no evidence of thrush. The cardiovascular exam demonstrated tachycardia, but was otherwise unremarkable. The lungs were clear to auscultation bilaterally. The abdomen was soft, non-tender, and non-distended with good bowel sounds. The extremities demonstrated no clubbing, cyanosis, or edema.

Table 1 .

Given the patient's pulmonary symptomatology, he underwent fiberoptic bronchoscopy to obtain bronchoalveolar lavage (BAL) fluid. The BAL fluid was stained and analyzed with the results shown in Figures 1A-D. A sonogram of the spleen was normal, while a computed tomography (CT) scan of the abdomen demonstrated patchy basilar lung disease, mild hepatomegaly, and normal kidneys. Chest x-ray showed a left posterobasal infiltrate as well as a retrocardiac infiltrate. A CT scan of the chest, without intravenous contrast, demonstrated no mediastinal or hilar adenopathy and the presence of a small pericardial effusion. In addition, both lower lobes of the lungs demonstrated a patchy consolidation with a ground-glass appearance. No destructive bone lesions were observed.

Patient's bronchoalveolar lavage fluid, illustrating stained spores of microsporidia (A, Gram stain; 1,000x magnification; B, Trichrome modified stain, 1,000x magnification) and (C,D) transmission electron micrographs, illustrating the transverse dimensions of a typical microsporidian spore recovered from the patient's BAL fluid.

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