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

2. 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

3. 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(+)

4. 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 (-)

5. Physical examination
Vital sign /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

6. 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

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

8. 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 : mg/dl

9. 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 (-)

10. Chest X-ray

11. HRCT

12. 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

13. 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

14. 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 : – 32.4mmHg – 59.8 mmHg – 21.5 mmol/L – 92.1%
(post bronchoscopy, VM / FiO2 : 0.4 )

15. HD 2 (2)

16. Bronchoscopy (1)

17. Bronchoscopy (2)

18. 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

19. 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(+)

22. 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

23. 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/CD
- 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

24. 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

25. 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 : – 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

26. HD 5 (4)

27. 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)

28. 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

29. HD 8 (2)

30. 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

31. 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