Case presentation
51 years old gentlemen with no previous medical history, presented with twenty days history of productive cough of yellowish sputum but sometimes mixed with minimal blood streaks. He also reported nocturnal fever, progressive shortness of breath accompanied with generalized fatigability, and significant unintentional weight loos about 15 Kg, with loss of appetite. He denies any other symptoms. He denies any history of IV drug use, tattoos. Works as a construction worker, married but he admitted to have a few extra-marital sexual relationships.
On admission he was febrile with temperature 38.9 but other vitals were within normal limits. On examination patient was cachectic and pale. neck examination was unremarkable. Chest examinations showed reduced air entery on right lower lung zone with coarse crackles and dullness percussion note. The rest of physical examination were completely unremarkable.
His lab on admission showed bicytopenia (anemia and thrombocytopenia) with Hb 8.5 mg/dL and platelets 127 x10^3/uL. later on, he developed pancytopenia with WBC reaching 1.9 x10^3/uL (absolute neutrophilic count 1.5 x10^3/uL and lymphopenia 0.3 x10^3/uL). liver function test, renal function test, were both normal. Peripheral smear showed normocytic normochromic anemia with thrombocytopenia and lymphopenia with few reactive lymphocytes. Blood test for HIV came back positive and accordingly other tests were sent. Sputum smear for Acid fast bacilli, and PCR came negative for TB but two weeks later his sputum culture came positive for mycobacterium other than tuberculosis, and at the same time his Quantiferon test was indeterminate. He underwent bronchoscopy with bronchoalveolar lavage (BAL) and two weeks later the BAL culture result came positive for mycobacterium other than TB, and pneumocystis jiroveci was detected, as well as candida albicans. Both CMV and EBV PCR were positive from BAL. Furthermore, two bottles of blood culture showed cryptococcus neoformans growth. His rapid plasma reagin (RPR) screening for syphilis was positive, confirmatory test with Treponema pallidum antibodies was reactive as well. Urine test for chlamydia trachomatis and Neisseria gonorrhoeae DNA both were negative.
Chest x-ray showed small patchy areas of airspace shadowing in the right lung base and to a lesser extent in the right infra clavicular region (Figure A). Computed tomography scan (CT) of the neck showed bilateral cervical and supraclavicular enhancing lymph nodes, some of which demonstrate central non-enhancing areas likely representing necrosis. The largest lymph nodes are seen at level 2A bilaterally measuring 8 mm in short axis dimension (Figure D). CT chest showed right lung ground glass nodular infiltration at posterior segment of upper lobe and apical segment of lower lobe, postero-basal collapsed consolidation. The left lung shows few nodular opacity 6x4 mm at lung apex, postero-basal atelectatic changes. mediastinal lymph nodes are noted largest at preaortic space measures 15x11.5 mm (Figure B and C). Infectious disease department (ID) and center of communicable disease (CDC) were notified according to our hospital policy and the Patient started on appropriate treatment including trimethoprime-sulfamethoxazole and steroid. The patient was discharge after the screening of other sexual transmitted disease and CD4 count were send and to follow the result at the clinic, and then to start anti-retroviral therapy (ART) accordingly. Unfortunately, later on after several days his blood cultures turn to be positive for cryptococcus neoformans, at that time the patient went back to his home country. Two weeks later his sputum and BAL cultures came positive for mycobacterium other than tuberculosis.