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‘ Difficult ’ Case 1. Sanjay Bhagani Royal Free Hospital and UCL, London. 34yr old male, from Brazil Married, no children 6 week history of intermittent fevers, dry cough, weight loss, shortness of breath on exertion HIV-1 positive, CD4 320 (17%), viral load 3300 c/ml HBV and HCV negative.

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Difficult case 1

Difficult’ Case 1

Sanjay Bhagani

Royal Free Hospital and UCL, London


  • 34yr old male, from Brazil

  • Married, no children

  • 6 week history of intermittent fevers, dry cough, weight loss, shortness of breath on exertion

  • HIV-1 positive, CD4 320 (17%), viral load 3300 c/ml

  • HBV and HCV negative


O/E

  • Thin and cachectic

  • Breathless at rest

  • Small lymph nodes in the cervical region

  • Skin - normal

  • HS – normal

  • Chest: fine crackles at bases, reduced air entry at bases

  • Oxygen saturation – 90% at rest

  • Hepatosplenomegaly


What s the differential diagnosis
What’s the differential diagnosis?



What was actually done
What was actually done?

  • High-dose intravenous co-trimoxazole

  • Intravenous methylpredinisolone 40mg bd

  • Intravenous amoxycillin-clavulinate

  • Oral clarithromycin

  • Transferred to our unit

  • Feels much better

  • CXR repeated day 3



  • Underwent bronchoscopy and BAL at day 4 to do other tests?

  • Cytology – no PJP

  • Smear negative, TB-PCR negative, no positive bacterial/fungal cultures

  • Serum CrAg, toxoplasma negative

  • Prednisolone reduced and stopped, continued on i.v antibiotics



Now what
Now what? to do other tests?


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