Medicine Case

[souljah1]

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40yo homeless man presents with two months of progressive dyspnea and subjective weight loss of 20 pounds. Progressive dyspnea associated with a dry cough that he states was seldomly productive. Three weeks ago he went to an out-patient clinic and was given doxycycline emperically to treat atypical PNA. He noticed litte, if any, benefit. Returned to the clinic one week ago with worsened SOB, CXR ordered and pulse ox of 95%. Concerned about Pt health, clinic set-up a room in a shelter. Pt presented to ED two days ago with severe dyspnea, O2 sat 88%, + chills/sweats. Denies hemoptysis, productive cough, neck stiffness, IVDU.

On exam, Pt afebrile, with nml blood pressure, slightly tachy, tachypnic at 26. Appears thin, ill. Shoddy cervical LAD bilaterally. Shallow breathing with course inspiratory crackles at both bases. Cardiac exam is benign, as is the abdominal exam. No c/c/e. No rash or skin changes. A&O, grossly nonfocal neuro exam

Labs and CXR pending.

Differential?
Other information you'd like to know?

 

[marchiafava]

40yo homeless man presents with two months of progressive dyspnea and subjective weight loss of 20 pounds. Progressive dyspnea associated with a dry cough that he states was seldomly productive. Three weeks ago he went to an out-patient clinic and was given doxycycline emperically to treat atypical PNA. He noticed litte, if any, benefit. Returned to the clinic one week ago with worsened SOB, CXR ordered and pulse ox of 95%. Concerned about Pt health, clinic set-up a room in a shelter. Pt presented to ED two days ago with severe dyspnea, O2 sat 88%, + chills/sweats. Denies hemoptysis, productive cough, neck stiffness, IVDU.

On exam, Pt afebrile, with nml blood pressure, slightly tachy, tachypnic at 26. Appears thin, ill. Shoddy cervical LAD bilaterally. Shallow breathing with course inspiratory crackles at both bases. Cardiac exam is benign, as is the abdominal exam. No c/c/e. No rash or skin changes. A&O, grossly nonfocal neuro exam

Labs and CXR pending.

Differential?
Other information you'd like to know?

First of many questions: does he drink or smoke?? what is his PPD status(that is if he ever had one)?? Is his dyspnea with moderate activity, resting, or PND, or any orthopnia?? Does he have a history of asthma, history of recent calf pains, hitory of chest trauma?


Along with the crackles at the lung bases, was there concominant egophony, bronchophony and whisper pectoriloquy??? Would be nice to know what type of CXR was done---PA, AP, oblique, or maybe expiratory to look for evidence of foreign body causing airtrapping??? Did he have JVP with or without hepatojugular reflex??? Any pulsus paradoxus, positive Homan's sign, no s3 or other gallop? Any muscle atrophy or fasics of tongue or abnormal reflexes, or swallowing difficulties??? Would like to know what was on the initial EKG, CXR and what his initial labs were.

Diff at this point would be:
1.Bronchospasm/asthma
2.PE with possible pleural effusions
3.CHF
4.pneumonia(aspiration)/consolidation
5.TB has to be considered
6.Obviously malignancy
7.I guess the possibilities exists for ALS if the exam correlated somewhat.
and others, but good for now

Plan from here dependent on labs, EKG and CXR.

 

[Resident Alien]

test him for hiv

 

[souljah1]

He states that he is a smoker, but has had to quit due to the SOB. He also had to cut down on methamphetamine use. States that PPD neg as of 6mo ago. Denies chest trauma, orthopnea, PND, calf pain, h/o asthma. If you asked him about sexual history he would tell you that he has had unprotected oral sex with more than 20 men over the past 5 years and has had unprotected oral/anal/vaginal sex with 2 women over 5 years.

Exam: no egophony, fremitus, or dullness to percussion. No JVD, hepatojugular reflex, pulsus paradoxus, S3/S4 or murmurs, Homan's sign. Only remarkable for cachexia and inspiratory crackles along with bilateral cervical lymphadenopathy.

Labs: CBC showed normal white count with 12% lymphocytes, microcytic anemia, thrombocytosis (630). Chem 7 nml. Low albumin with corrected Calcium. LDH of 725. HIV and Cd4 pending
CXR: PA showed bilateral interstitial infiltrates in a diffuse pattern with no evidence of pneumothoraces or effusions. The heart appears to be of normal size.
ECG: Sinus tachycardia

So, you have a man with multiple risk factors for HIV with progressive dyspnea and constitutional symptoms who failed a course of doxycycline for presumed atypical pneumonia and whose CXR showed diffuse bilateral interstitial infiltrates.

What is your differential now for his dyspnea?
What do you make of his high LDH?
What kinds of things can give you CXR findings such as these?
Empirical treatment?

 

[snowinter]

ldh

interstial infiltrates

are you trying to get at PCP pneumonia?

bactrim /steroids


(sorry i'm learning how to quote text not surehow).

 

[souljah1]

Yes, PCP is the diagnosis. LDH is sensitive but not specific, for it can be increased in many parenchymal problems of the lung. The CXR description is classic for PCP, however PCP can occur with a nml CXR. We started empirical prednisone and trimethoprim/sulfa and continuous O2. Prednisone should be started with a PaO2 <70 or an elevated A-a gradient > than 35.

We inducted sputum, which stained positive for PCP. Shortly after, Cd4 count came back from the lab = 108 (7%). HIV Ab and viral loads will be back shortly.

Interesting case in that this is an initial presentation of AIDS. Reminded a lot of the faculty of the 1980s. This isn't all that uncommon lately, which is unfortunate.