Clinical Tropical Medicine 
Christian Medical College, Vellore, Tamilnadu, India

History

34 year old lady who was known to be HIV infected for 10 years was started on generic antiretroviral therapy (ART) with zidovudine, lamivudine and nevirapine in June 2013 after a CD4 count was found to be 214 cells/µl on a routine evaluation. Two weeks later she presented with a dry cough and breathing difficulty which developed over 3 days and rapidly worsened to present state where she was breathless at rest. She had associated high grade fever, intermittent with no chills or rigors. She also complained of mild loss of weight and appetite.  There was no history of orthopnoea, paroxysmal nocturnal dyspnea, chest pain, pedal edema or decreased urine output. No other significant history. She was diagnosed to have sputum positive pulmonary tuberculosis 6 years ago but defaulted antituberculous therapy (ATT) after 2 months of DOTS therapy under the Revised National TB Control Programme (RNTCP). She was also found to have genital herpes and oral candidiasis and was treated for both 4 months ago.

On examination

Patient was conscious and in distress. There was no pallor, icterus, cyanosis, clubbing, generalized lymphadenopathy or pedal edema.

Pulse - 120/min, Blood Pressure - 100/80 mm Hg, Saturation was 70% on room air

Cardiovascular system: S1, S2 heard no murmurs.

R.R - 50/min

Respiratory system: Bilateral infra axillary crepitations and ronchi were present. Bilateral bronchial breath sounds were present.

Abdomen: Soft, no masses palpable, no evidence of free fluid.

Central nervous system: No focal neurological deficits.

Musculoskeletal system: Normal.

Skin: Normal.

 

Investigation

CBC PROFILE                                                             

            Differential count: Neutrophils: 71 Eosinophils: 2 Basophils: 1 Monocytes: 9   

                                           Lymphocytes: 17                 

 

            MCV                                       76.3                 fl            

            MCH                                       25.0                 PG            

            MCHC                                     32.7                G/DL          

            RDW                                       15.0                 %             

            Total WBC                              5200                /CUMM         

            Hb                                           10.8                 GM/DL         

            Platelet Count                         375000             /CUMM         

            RBC                                       4.31                         

            HCT (PCV)                             32.9                 %             

           

  LFT                                                                    

            Bilirubin Total                         0.2                   mg%           

            Direct                                      0.1                   mg%           

            Protein Total                           8.9                   g%            

            Albumin                                  3.3                   g%            

            AST (SGOT)                           75                    U/L           

            ALT (SGPT)                           23                    U/L           

            Alkaline Phosphatase             114                   U/L           

           

LDH                                                     977                 U/L           

Serum Electrolytes                                                     

            Sodium                                    134                  m mol/L       

            Potassium                                 4.1                  m mol/L       

            Bicarbonate                              18                   m mol/L  

    

Urea                                                     25                    mg%           

Creatinine                                            1.03                 mg%           

Culture Blood – NO GROWTH           

                   

                           

Xpert TB PCR TEST: MTB NOT DETECTED    on     BAL Sample                                                               

C/S Sputum Common    : No Pus Cells, No Bacteria                                                

                      Normal Flora                 

Sputum Mycobacteria Culture & Sens 1st Line (MGIT AUTO)                               

            No AFB seen on smear       - Culture awaited              

Multiple sputum AFB smears - Negative                                     

Arterial Blood Gas on 100% oxygen by reservoir bag                             

            pH(T)                                      7.45                         

            pCO2                                       27                   mmHg          

            pO2                                         126                  mmHg          

            Lactate                                     0.9                  mmol/L        

            Base excess                             -5.2                  mmol/L        

            HCO3                                     18.8                 mmol/L        

               

  Chest x-Ray: ON ADMISSION

 

Bilateral homogenous opacification perihilar and lower lung fields

 

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