Polly Myalgia is a 39 year old woman who has presented to A&E with shortness of breath and a cough. The cough is non-productive, and the breathlessness is worse on exertion. She has been feeling hot and cold over the past few days, with aches and pains in her joints. However she states that this is quite normal for her, as she has been 'very run down' for a long time. She declines to give you any past medical history, simply saying she 'isn't very well'. On reviewing online notes, it appears she had previously attended infectious diseases clinics at your hospital, with multiple non-attendances and has been lost to follow up. She says she previously took some 'complicated medicine' but it made her feel unwell so she stopped.
On chest examination, she has scattered crackles at both lungs. Abdominal exam demonstrates splenomegaly. On inspection she has a white slough on her tongue, which cannot be scraped off. She has a brown, nodular lesion on her right upper arm and on her left foot, which are not tender. Inspecting her arms you note multiple scars from likely needle insertion.
Initial blood tests, undertaken by the nursing team, have come back:
Hb - 121
WCC - 3.2
Urea - 7.2
Creatinine - 78
LDH - Elevated
Over to you - what would you like?
Chest X Ray report: perihilar fluffy shadows evident ?consider immunodeficiency cause
HIV screen: POSITIVE
Blood culture: sample will be cultured over period of five days, after 24 hours no evidence of growth
Now select your winner!
You picked:
Correct answer:Pneumocystis jirovecii
The options in this case are mostly causative organisms in pneumonia. The clue here is in the risk factors. A combination of 'history of being known to infectious diseases', 'needle' marks, and the chest X ray report point to a chronic infectious process. The white slough on her tongue may be candida, but it cannot be brushed off, hinting at hairy cell leukoplakia, caused by EBV and associated with AIDS. This appears to be in association with brown nodular lesions, likely Kaposi Sarcoma, also an AIDS defining illness. The HIV screen is furthermore positive. Of the options, pneumocystis jirovecii is associated with AIDS, and therefore the correct answer.
