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.