1. Case studies in OI management
Module 4 Sub module case studies OI

2. Case study 1
24 year-old man with oral thrush, presented with low grade fever, progressive dyspnea on exertion and dry cough for 2 weeks
Physical examination showed
T 38.5°C, RR 26/min, O2 saturation was 97% on room air but decreased to 90% with minimal exertion.
No cervical lymphadenopathy. Lung clear to auscultation
CXR as shown

3. Case study 1
What is the differential Dx?

4. Case study 1 Differential Dx: - PCP - Miliary TB
- Disseminated fungal infection
- CMV infection
- Bacterial e.g. Salmonella

5. Case study 1 What will you do? a. Start empirical Rx for PCP
b. Sputum examination and await result
c. Fiberoptic bronchoscopy with BAL (if available)

6. Case study 1
BAL result : PCP

7. Case study 1 Presumptive PCP & Empirical Rx :
correct Rx in 72% ( CDC criteria : HIV+, dyspnea, nonproductive cough, no previous prophylaxis, had previous H/O PCP, CXR: diffuse interstitial disease with moderate hypoxemia )
In severe or atypical cases : Early FOB
In slow or non-responded cases after empirical Rx for 3-5 days : FOB
FOB: procedure of choice for Dx PCP
Sensitivity of BAL >95% if no Rx
Trans bronchial biopsy is not necessary but may be helpful for Dx of concomitant infections

8. Case study 2
28 yr-o female, known HIV positive for 5 yrs, presents with headache
1 month history of progressive headache without fever or neurological deficit
No previous opportunistic infection except herpes zoster 8 moths ago at her left chest wall

9. Case study 2: Physical exam
T 37.2oC BP 110/60 P 90/min RR 20/min
Oral thrush
Pruritic papular eruption rash over extremities
Other general exam unremarkable
Neuro exam: fully conscious, cooperative
Cranial nerves: intact
Motor and sensation: intact
Stiff neck positive, mild photophobia
Pupil 3 mm, equal, reactive to light,
Fundus: no papilloedema

10. What is the most likely diagnosis? What is the appropriate management?
Serum cryptococcal Ag: positive >1:100
LP: pressure 40cm Hg (high)
RBC 5 cells/mm3, WBC 50 cells/mm3
Protein 88, sugar 60/98
India ink +ve
What should be the management?