1. 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.

2. 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.

3. 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.

4. What is your differential diagnosis?

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

6. 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

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

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

9. 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)

10. 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.

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

12. 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.