Case Presentation
A 39-year-old, transgender female with no significant past medical
history presented to the hospital with complaints of a persistent cough
of a 4-month duration. The patient stated the cough was productive with
whitish sputum and was associated with weight loss, night sweats, loss
of appetite, and low-grade fever. Three weeks prior to the hospital
admission she had visited the emergency room with similar complaint and
was discharged with oral antibiotics for community acquired pneumonia.
However, symptoms persisted despite completion of antibiotics prompting
a second visit to the hospital. During the second visit, patient was
admitted for further evaluation. On initial presentation, the patient
was febrile T- 100.4 F, HR 106 bpm, with blood pressure of 113/71 mmHg
and an O2 saturation of 96% on room air. The patient was not in acute
distress, was alert awake and oriented times three. Physical exam was
notable for pink conjunctiva, non-icteric sclera, no oropharyngeal
lesions, no lymphadenopathy, chest examination revealed good air entry
bilaterally with diffuse crackles worse on right upper posterior lung,
resonance to percussion, S1 and S2 heard, no murmur or gallops, jugular
venous pressure not raised, abdomen is soft, normal tympanic sound, no
tenderness or organomegaly, extremities showed no edema or skin lesions.
No focal neurologic deficit.
Given the above history and physical examination, the patient was being
evaluated for HIV and pulmonary TB. Labs showed WBC 13K/ul, Hemoglobin
11 g/dL, Platelets 574 k/ul, elevated ESR 110, LDH 193 U/L, chemistry is
within normal limit, HIV test positive, CD4 count of 73 cells/mcL, viral
load 559000 copies/mL, sputum AFB negative x3, Grocott’s methenamine
silver stain for Pneumocystis Jiroveci Pneumonia (PJP) was negative.
Chest x-ray (figure 1) revealed left lower lobe a patchy to confluent
opacity with air bronchograms. CT chest showed: left lower lobe
consolidation and tree-in-bud appearance with the nodular opacity as
seen in Figure 2.
During hospitalization, the patient was being treated for community
acquired pneumonia with ceftriaxone and azithromycin. All of her tests
for pulmonary tuberculosis was negative and she was discharged home
after mild symptomatic improvement. Prior to discharge patient was
started on PJP prophylaxis and Highly Active Antiretroviral Therapy
(HAART) for HIV positive patient with AID’s. On subsequent visit to the
infectious disease clinic, she continued to have persistent cough with
other constitutional symptoms. Physician revealed that her respiratory
culture was positive of MAC identified by DNA probe. Patient was
prescribed standard the MAC treatment regimen: Azithromycin 500 mg
daily, Rifampin 600 mg daily, and Ethambutol 25mg/kh/day for a duration
of 12 months. On subsequent follow up in infectious disease clinic she
showed marked improvement of her symptoms.