Difficult case 1
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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

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Difficult case 1

‘Difficult’ Case 1

Sanjay Bhagani

Royal Free Hospital and UCL, London


Difficult case 1

  • 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


Difficult case 1

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 would you do next

What would you do next?


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


Difficult case 1

  • Are we happy that we have the right diagnosis or do we need to do other tests?


Difficult case 1

  • Underwent bronchoscopy and BAL at day 4

  • 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


Difficult case 1

  • Day 7 – fevers return

  • More breathless

  • CXR


Now what

Now what?


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