호흡곤란과 마른기침으로 내원한 23세 남자 Division of Infectious disease MGR 호흡곤란과 마른기침으로 내원한 23세 남자 Division of Infectious disease

11897367 HS YOU M/23 Chief complaint > dyspnea ( MRC grade II ) o/s ) recent : 1 wk ago remote : 4 months ago Present illness > - 23세 남자 환자, 내원 4개 월 전부터 dry cough, 야간에 발생하는 intermittent febrile sense, chilling 으로 개인 의원에서 3차례에 걸쳐 URI 에 대해 치료 받았으나 증상 지속됨 - 최근 5개월 간 8kg 정도의 체중 감소와 함께 피로감 지속되어 입원 2주 전 본원 내원하여 건강검진 시행 받았으며, 당시 흉부 방사선 검사에서 retuculonodular opacity 확인되고, 혈액검사 결과 anemia 소견으로 혈액종양내과 외래 진료 후 HRCT 촬영 및 호흡기내과 치료 권유받음 - 내원 일주일 전부터 dry cough 에 동반된 dyspnea ( MRC grade II )심해져 본원 호흡기 내과 외래 진료 후 입원

DM (-) HTN (-) Tb (-) Hepatitis (-) Op Hx (-) Past medical history DM (-) HTN (-) Tb (-) Hepatitis (-) Op Hx (-) HIV (+) : 2007년 4월 17일 건강검진 Family history None Personal history Alcohol (+) : social drinking Smoking (+) : 5 pk / yr Occupation : 판매직 종사 중 휴직 상태 Sexual contact history : 1st exposure (10대 중반, heterosexual ) 직업여성과의 sexual contact history (+) Military history (-) Blood transfusion (-) , donation(+)

Review of Systems General : fatigue (+) fever (-) chills (-) night sweat (-) weight loss (+) : 5개월간 8kg Skin : rash (-) itching (-) pigmentation (-) Head / Neck : headache (+) sore throat (+) Respiratory : cough (+) sputum (+) dyspnea (+) Cardiac : orthopnea (-) chest pain (-) palpitation (-) GI : A/N/V/D/C (-/-/-/-/-) melena (-) abdominal pain (-)

Physical examination Vital sign 110/70 mmHg – 90/min – 18/min – 36.5 °C Height : 177cm Weight : 58kg BMI : 18.51 General appearance - Alert mentality - Acutely ill looking appearance Skin - No rash or pigmentation Head & Neck - No cervical / supraclavicular lymph node enlargement - No neck vein engorgement

Eyes and ENT - Isocoric pupils with PLR (++/++) - Whitish sclera & Pinkish conjunctivae - Pharyngeal injection (+) - PTH (-/-) Chest - Coarse breath sounds with crackle at both lung field - Regular heart beats without murmur Abdomen - Soft and flat abdomen - Normoactive bowel soud - No tenderness or rebound tenderness - No palpable abdominal mass

Back and Extremities - CVA tenderness ( - / - ) - Generalized edema (-) - Pretibial pitting edema ( - / - ) Neurology - Neck stiffness ( - ) Kernig sign(-)

Initial Lab Results (1) CBC/DC 3910/mm3 – 10.7 g/dL– 31.1 % - 110K/mm3 (Seg 80.5%, Lymph 12.1%, Mono 3.9%, Eosino1.9 %) ESR : 79 mm/hr aPTT 44.5/34 INR 1.01 Chemisrty TB/DB 0.54/0.16 mg/dL ALP 109 U/L GGT 41 U/L Prot/Alb 6.8/2.5 g/dL AST/ALT 25/18 U/L LD 495 U/L Ca/P 8.3/4.0 mg/dL Bun/Cr 6/0.6 mg/dL Na/K/Cl 140/3.7/107 mmol/L HDL 47 mg/dL LDL 67 mg/dL TG 93 mg/dL T-chol 144 mg/dL CRP : 0.9 mg/dl

Initial Lab Results (2) ABGA (Room Air) 7.448– 34.3mmHg – 75.1 mmHg – 23.2 mmol/L – 95.7% (A-a)DO2 : 31.7mmHg Urinalysis RBC 0~1/ HPF WBC 0~1/ HPF Stool exam Helminth (-) Protozoa (-) Occult blood (-)

Chest X-ray

HRCT

Initial Assessment / Plan Problem list #1. HIV infection (+) #2. dry cough and dyspnea #3. weigh loss #4. fatigue #5. chest X-ray & chest CT : reticulonodular opacity #6. pancytopenia Assessment #1. HIV infection #2. Pneumocyctis carinii pneumonia r/o CMV pneumonia, r/o Tbc #3. AIDS wasting syndrome

Initial Assessment / Pan Plan #1. HIV infection & #3. AIDS wasting syndrome - HIV infection state evaluation : CD3,CD4,CD8, RNA PCR - opportunistic infection evaluation : Toxoplasma Ab, PPD test, Sputum AFB, CMV Ab, hepatitis viral Ab,안과검진 - AIDS medication if needed #2. Pneumocyctis carinii pneumonia r/o milliary Tbc, r/o CMV pneumonia - f/u chest X-ray - sputum exam : AFB stain, Tb culture, PCP staining, PCP PCR - bronchoscopy : washing, BAL, TBLB - medicaition for PCP, anti Tbc medication if needed

HD 2 (1) #2. Pneumocyctis carinii pneumonia with known HIV infection r/o CMV pneumonia, r/o Tbc S> febrile sense(-), chilling(-) dyspnea (+) : post bronchoscopy cough : productive sputum : yellowish, thick, mucoid 0> V/S 120/90 mmHg – 100/min – 24/min – 36.4 °C coarse breath sound with crackle at BLF ABGA : 7.439 – 32.4mmHg – 59.8 mmHg – 21.5 mmol/L – 92.1% (post bronchoscopy, VM / FiO2 : 0.4 )

HD 2 (2)

Bronchoscopy (1)

Bronchoscopy (2)

HD 2 (3) Bronchoscopy - Vocal cord : bilateral symmetrical - Trachea : negative - Carina :sharp , mobile - Rt : No endobronchial lesion, BAL 150cc -> 120cc ; Clear - Lt : No endobronchial lesion - BAL fluid : RBC 103/mm3 WBC 29/mm3 ( Neutrophil : 4% lymphocyte : 44% mesothelial cell : 8% eosinophil : 1% monocyte : 2% histiocyte : 41% ) - TBLB

HD 2 (4) Bronchoscopic biopsy - Gross Description : Submitted for 2 discs of gray-white mucosal tissue - Micro : Section disclose portion of lung showing eosinophilic, amorphous materials deposition in the dilated alveolar spaces - Diagnosis : Pneumocystis carinii pneumonia, consistent with - Special stain finding: G.M.S(+)

HD 2 (5) #2. Pneumocyctis carinii pneumonia with known HIV infection r/o CMV pneumonia, r/o Tbc A> Pneumocyctis carinii pneumonia with known HIV infection P> O2 supply Bactrim medication : 15mg of TMP /kg iv div. q8hr Steroid medication : prednisolone 40mg bid

HD5 (1) #1.HIV infection - 확진 : 2007년 4월 17일 - 면역 검사 결과 - 확진 : 2007년 4월 17일 - 면역 검사 결과 (1) 2007년 4월 23일 : WBC 11,480/mm3 , Lymphocyte 688/mm3 (6.0%) CD4 10 /mm3 (1.5%) , CD8 240/mm3 (35.9%) CD4/CD8 0.04 - 기회감염 혈청 검사 (1) VDRL: (-) (2) Toxoplasma IgG : ( - ) (3) HBs Ag(-), HBs Ab (+-), HBc Ab (-) (3) CMV IgM (-), CMV IgG (+) (4) Anti HCV : (-) (5) PPD test : (-) 결핵균 특이항원자극 IFN-γ : indeterminate

HD5 (2) - Plan (1) RNA PCR 결과 확인 (2) AIDS medication start (HAART therapy) : Zidovudine 300mg bid Lamivudine 150mg bid Kaletra ( Lopinavir 200mg + Ritonavir 50mg ) 500mg bid (3) CD4 and CD8 count F/U (4) 안과 검진

HD 5 (3) #2. Pneumocyctis carinii pneumonia with known HIV infection S> febrile sense(-), chilling(-), dyspnea (-) cough : dry sputum : whitish, small amount 0> V/S 110/70 mmHg – 88/min – 22/min – 36.4 °C clear breath sound without crackle ABGA : 7.456 – 28.8mmHg – 78.4 mmHg – 17.6 mmol/L – 95.7% (Room Air ) CBC : 11,480/mm3 – 10.1 g/dL– 29.3 % - 168K/mm3 ESR : 42 mm/hr CRP : <0.5mg/dL

HD 5 (4)

HD 5 (5) #1. Pneumocyctis carinii pneumonia with known HIV infection A> Pneumocyctis carinii pneumonia with known HIV infection P> O2 stop Bactrim medication : 15mg of TMP /kg div. q8hr PO Steroid medication : prednisolone 40mg qd (tapering)

HD 8 (1) #1. Pneumocyctis carinii pneumonia with known HIV infection S> febrile sense(-), chilling(-), dyspnea (-) cough (-) sputum (-) anorexia(-) nausea(-) vomitting(-) 0> V/S 110/70 mmHg – 80/min – 20/min – 36.4 °C clear breath sound without crackle CBC : 6,210/mm3 – 10.5 g/dL– 30.3 % - 223k/mm3

HD 8 (2)

HD 5 (3) #1. Pneumocyctis carinii pneumonia with known HIV infection A> Pneumocyctis carinii pneumonia with known HIV infection P> Bactrim medication : 15mg of TMP /kg div. q8hr PO Steroid medication : prednisolone 20mg qd

Discharge Plan Treatment for PCP - Bactrim : 15mg of TMP /kg div. q8hr PO ( total 21days)  preventive dose 유지 Treatment for AIDS - Zidovudine 300mg bid Lamivudine 150mg bid Kaletra ( Lopinavir 200mg + Ritonavir 50mg ) 500mg bid - drug adverse reaction f/u - CD4/CD8, RNA PCR f/u Prevention for opportunistic infection - Clarythromycin 500mg bid for M. avium - PPD test f/u