A 26 year old woman with shortness of breath

A 26 year old woman from rural West Bengal presented with dyspnea on exertion, gradually progressing since 1 year, with an occasional dry cough. She reported no fever, weight loss, hemoptysis, orthopnea or wheezing. She reported being treated for hydatid disease 8 years prior (albendazole for 1 month). She reported multiple stray dogs in and around her home. Examination revealed reduced breath sounds in the left infrascapular and infra-axillary areas. The liver was palpable 3 cm below the costal margin.

Chest radiograph revealed homogenous mass-like opacities in the left lung. A CT of abdomen and chest revealed multiple large cysts in the left lung, liver, and abdomen, with a thick walled cavity in the left lung base.

The patient was diagnosed with disseminated hydatid disease. The extensive intramdominal and thoracid disease was deemed surgically non-operable, and the patient was advised long-term albendazole therapy.

Disseminated (pulmonary, hepatic and intrabdominal) hydatid disease

38 year old man with fever and dyspnea

A 38 year old man presented with a 2 month history of weight loss and generalised weakness. He reported low grade fever, dry cough and shortness of breath since 10 days. Examination revealed tachycardia, tachypnea, and bilateral rales on chest auscultation. Multiple non-tender cervical nodes were present. Pulse oximetry showed a oxygen saturation of 85% while breathing ambient room air. The chest radiograph showed few ill defined infiltrates in the lower lung fields.

HIV ELISA was positive for antibodies to HIV-I. CT scan of the chest showed bilateral extensive ground glassing. An induced sputum was negative for pneumocystis by Gomori methenamine stain. Aspiration of the cervical node showed numerous acid fast bacilli on the ZN smear. Xpert MTB RIF was positive (with no rifampicin resistance) on the lymph node aspirate. The sputum AFB smear and Xpert MTB RIF were negative. The CD4 count was 28 cells/μl. The HIV-I viral load was 27,000 copies/ml.

TMP-SMX was started at a dose of 15 mg/kg (trimethoprim component). Antituberculous therapy (HRZE) was initiated. Prednisolone 40 mg twice daily was started.

The patient’s course was marked worsening of tachypnea and oxygenation in the second week of treatment. Intercurrent drug-induced hepatitis developed and the ATT regimen was switched to levofloxacin, ethambutol, and streptomycin. Trimethoprim associated hyperkalemia was managed with sodium polystyrene sulfonate. Supplemental oxygen was discontinued after 3 weeks of treatment. Cervical lymph nodes regressed significantly over the hospital stay. Antiretroviral therapy with TDF/FTC/EFV was introduced after 4 weeks.

(Probable) Pneumocystis jirovecii pneumonia and tuberculous cervical lymphadenitis in HIV/AIDS WHO Stage IV