HPI A previously healthy 33 year old male complaining of progressive nonproductive cough for 2 months. He became more short of breath with exertion in the last week, and states that he has lost 10 lbs in the last 4 months despite having a good appetite. He has had chills mostly at night for about the same period. ROS: Denies wheezing, flu-like sxs, diarrhea, odynophagia, LE edema, PND or orthopnea.

HPI continued Allergies: NKDA Past Medical Hx: none Past surgical Hx: appendectomy at age of 13. Family Hx: mother: HTN Social Hx: construction worker. No tobacco, ethanol or illicit drug use. Sexually active with women. 10 Sexual partners in lifetime. No hx of STIs.

Physical Exam Vitals: T 38.5, BP 115/65, HR: 101, RR 22, Osat 90% General: In some distress. Acyanotic, alert and oriented x3 HEENT: normocephalic, TM clear bilaterally, PEERLA, EOMI, no oral thrush or ulcerations. + cervical nontender lymphadenopathy bilaterally. Neck: Supple, no JVD. No carotid bruits. Chest: RRR, normal s1 s2, no murmurs, rubs or gallops. Extremities: No LE edema, no clubbing, no rashes.

What is your differential diagnosis?

Differential Dx: Pneumonia Lung abcess CHF COPD Pleuritis Costocondritis Congenital Heart Disease

Laboratory and Imaging CBC : WBC decreased BMP: normal Induced sputum stain and culture: pending CXR: pending HIV work up CD4 count: 120 cells/mm3 Rapid HIV test: positive

Imaging 1.PA view. Normal Chest Radiograph 2. Diffuse ground glass opacification without air bronchograms and without obliteration of the pulmonary vessels.

Induced Sputum Methenamine silver stain. Ovoid, to cup-shaped organisms with focal thickening of the cell wall Pneumocystis jiroveci Giemsa stain. Foamy alveolar exudate

What is Pneumocystis jiroveccii pneumonia? Classic clinical presentation: insidious onset of cough ( +/- sputum production), dyspnea and fever. Other symptoms include fatigue, chills, chest pain, and weight loss. Epidemiology: affects immunocompromised individuals. It is the most common outpatient infection in HIV+ individuals ( 90% of patients have a CD4 count <200 cells/mm3)

Physical Exam findings Tachypnea Hypoxemia Fever >38.5 Pulmonary symptoms: Crackles and rhonchi, but 50% of examinations can be normal. Extrapulmonary symptoms: lesions in the liver, spleen ( hepatosplenomegaly) kidney and brain.

Diagnosis Identify the organism: - Induced sputum - Bronchoalveolar lavage if sputum negative. - P. jirovecci identified via methenamine silver or Giemsa stain. - Immunofluorescent staining. Most sensitive.

Treatment TMP-SMX for 21 days is the preferred treatment for P. jirovecci pneumonia. Prophylaxis with TMP-SMX : start in all HIV patients with CD4 count is <200 cells/mm3.