A 30-year-old male.
She reported dry cough with a date of one month, night sweats, progressive respiratory distress and estimated weight loss of 10 kg. She reported no fever and a week before being admitted to hospital she had liquid diarrhea.
He had a history of homosexuality and gonorrhea 8 years earlier.
The patient was admitted with a temperature of 37oC, oriented vigil blood pressure of 100 pulses of 108/min, tachypnea and respiratory rate of 50/min.
blepharopathies, blepharopathies, non-adherent to deep planes and painless, both lateral and pharynx as well as axillary and inguinal plaques
Cardiovascular and abdominal examination showed no pathological findings.
The following diagnostic hypotheses were raised: pneumonia to respiratory failure; oropharyngeal candidiasis; HIV infection?
Treatment was initiated with oral cotrimoxazole 1600 mg (sulfa) every 8 hours and itraconazole 100 mg every 12 hours, plus prednisone 40 mg daily and 50% oxygen.
Laboratory examination revealed: LDH 833 U/L; hematocrit 44%; leukocytes 6,900 x mm3 (segmented 87%, lymphocytes 8%).
Chest X-ray showed bilateral infiltrates, with no other abnormalities.
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Episodes of fever and polypnea maintained 50% contribution to achieving FiO2 90-92%. Antimicrobial agents were administered every 5 days to the Intermediate Treatment Unit Infective therapy 1 g.
15 days after admission, the patient developed severe back pain.
A new chest X-ray showed multiple bullous lesions, as well as pneumothorax in both lung fields.
Evaluated jointly by bronchopulmonary specialists, thoracic surgeons and infectologists, the diagnosis of bilateral bullous disease with pneumothorax less than 15% was made, which discourages the use of pleural tube.
In addition, the contraindication to mechanical ventilation was raised.
A chest CT confirmed this diagnosis.
The HIV ELISA test was (+) and later confirmed in the reference laboratory (ISP).
The presence of P. jiroveci was documented by DFA test.
The CD4 lymphocyte count was 3 x mm3.
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poor response on day 17 of hospitalization was added to the aforementioned vancomycin, amikacin and antifungal therapy with isoniazid, rifampicin, pyrazinamide and ethambutate therapy.
Oxygen requirements increased and a high flow mask remained.
Subsequent radiographs showed rapid progression of the size of the existing bullae and the appearance of new images in both hemithorax.
The chest surgery team reassessed the case, advising an expectant management, because the placement of an intercostal tube or open surgery would worsen the patient's situation, and there was little chance to tolerate it.
The placement of a Heimlich valve would be an optimal indication, but only with an increase in pneumothorax.
He remained stable in his severity until the 21st day of his hospitalization, in which he again began with intense right chest pain, great ventilation premium, cough to die, with no increase in respiratory rate initiated evacuation.
