Case 18--Progressive Dyspnea in an AIDS Patient--An Unusual Cause

The clinical summary was contributed by Dr. George Verghese and Dr. Alison Morris.

Clinical summary: A 35-year-old white woman was seen in the clinic for exertional dyspnea and dry cough of approximately 2 weeks' duration. There were no fevers or weight loss. She was HIV-positive with a CD4 nadir of 116/µl but had no prior opportunistic pulmonary infections. Her CD4 count responded well to experimental therapy with combination antiretroviral therapy including protease inhibitors. She was a former intravenous drug user and crack smoker, but did not smoke cigarettes and had abstained from drugs for several years. She had no recent travel, and was PPD negative. For several years, she had had pet dogs and love birds. Physical examination was normal, and she was afebrile. Room air oxygen saturation at rest was 93%, and arterial blood gas analysis showed pH 7.41, pCO2 37 mmHg, and pO2 70 mmHg. A chest radiograph was normal. The CBC was normal except for mild eosinophilia (14%, 600/µl). PFTs showed normal lung volumes and flow rates, but the DLCO was 65% of predicted. Induced sputum showed no pneumocystis or AFB, and bronchoscopy with BAL yielded no pathogens. Dyspnea and cough worsened. HRCT of the chest was obtained. Transbronchial biopsy was nondiagnostic, and cultures and cytology were again negative. Lavage fluid showed moderate numbers of neutrophils and rare eosinophils. BAL lymphocyte subset analysis showed 97% CD3+ T lymphocytes, with 39% CD4+ and 55% CD8+ T cells (CD4/CD8 ratio 0.7). The ratio was similar in the peripheral blood. The total peripheral blood CD4 count at this time was >200/µl. Because the diagnosis was not apparent, a thoracoscopic lung biopsy was performed.

Histologic changes:Image 1 | Image 2 | Image 3 | Image 4 | Image 5 | Discussion

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