Wednesday, May 19, 2010

Double Diagnosis

A 40 year old man with hepatitis C presents with a subacute onset of fever, nonproductive cough, and shortness of breath. These symptoms have been getting progressively worse over the last few weeks. Other than hepatitis C contracted from IV drug use, he doesn't know about a past medical history. He hasn't seen a physician in years. He takes no medications. He occasionally drinks, smokes, and does IV drugs. Review of systems is positive for fatigue, chills, chest pain, and weight loss.

Physical exam is notable for a temperature of 38.3 C and respiratory rate of 26. His heart rate and blood pressure are normal. The rest of his exam including cardiac, pulmonary, and abdominal exams are normal. A chest X-ray is shown below.

LDH is elevated. An induced sputum is done with inhalation of hypertonic saline. The slide is stained and shown below:

Challenge: Unfortunately, two separate diagnoses can be made here. What are they?

Related Questions:
1. What does the CXR show?
2. What does the second image show?

Both images are in the public domain.

3 comments:

Elden said...

Still premed so totally guessing in the dark. lol
I'm basing this on the IV drug abuse.

But is it Pneumocystis Pneumonia caused from being infected with HIV?

Suheil said...

PCP and HIV? The chest X-ray shows bilateral interstitial shadows (ground glass appearance). I dunno wat the slide shows..

Craig Chen said...

yes! exactly right!
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Double Diagnosis

This patient has PCP (pneumocystis jirovecii pneumonia) which is an HIV/AIDS defining illness. The CXR shows bibasilar opacification (nonspecific) and the second image shows diagnostic cysts.

Sources: UpToDate; Wikipedia.