A 41-year-old male with a history of chronic smoking, 15 pack-years suspended three months prior to admission, without known chronic diseases.
She presented with a three-month history of cough with poor mucous expectoration, associated with fever, malaise, decreased functional capacity, asthenia and adynamia.
In addition, the patient reported liquid stools without pathological elements, 4 to 5 daily episodes, without vomiting or abdominal pain.
Two weeks prior to admission, diarrhea became more frequent (10 episodes per day), of similar characteristics, with no increase in respiratory symptoms.
Examinations were performed three weeks prior to admission, highlighting a 35% haematocrit, ESR 101 mm/h, polymerase chain reaction (PCR) in stools for negative Clostridium difficile and coprocultive.
Serology for HIV (ELISA) reactive, with subsequent confirmation at the Institute of Public Health (ISP) and CD4 lymphocyte count of 35 cells/ mm3, HLA-B 5701 negative.
Chest and abdomen computed axial tomography (CAT) showed ground glass zones in both lung fields associated with adenopathy and infra-diaphragm defined supra nodular lesions less than 2 cm and multiple hepatic lesions.
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Located in the Polyclinic of the Arriarán Foundation with the clinical picture described associated with weight loss of 15 kg, commitment of general condition, fever up to 39°C and severe fever on physical examination.
Blood tests showed a creatinine level of 2.0 mg/dL and urea nitrogen of 38 mg/dL.
She was admitted with the diagnosis of chronic diarrhea with significant weight loss associated with severe immunosuppression, constipation and acute renal failure.
Treatment was initiated with parenteral hydration, cotrimoxazole (20 mg/kg/day based on trimethoprim), at once weekly ART with abacavir, lamivudine and atazanavir/ritonavir.
The patient recovered satisfactorily without respiratory symptoms, but remained between 8 and 10 episodes of liquid stools a day, without other significant findings on physical examination.
Among the tests performed at admission, the patient had a hematocrit 27.6%, leukocytes 1.940 clito albumin mm3, 27.3% normal, creatinine dL, mg lactate dehydrogenase 200 mg/HHS > 100 mg/dL
Serology for HBV and HCV were negative.
Urine, urine and blood tests were also negative.
The chest X-ray showed an extensive diffuse bilateral reticulum-interstitial infiltrate with perihilar opacities, with no images of consolidation or pleural occupation.
Due to imaging suspicion of P. jiroveci pneumonia, bronchoalveolar lavage (BAL) was performed.
The airway was normal with no secretions.
Bacterial and Koch cultures and BAL fluid smears were negative.
Cytology with Gro staining showed a small group of cysts compatible with P. jiroveci.
Treatment was continued with cotrimoxazole initiated on admission.
Concomitantly, within the etiological study of chronic diarrhea in immunocompromised patients, negative coprocultive and negative Clostridium difficile toxin were performed, Serial parasitological examination of stools (EPSD) with negative Burllifluores spp staining.
Complete colon cleansing was performed which showed a cecal ulcer of 30 mm in diameter and 3 mm sessile polyp in the sigmoid colon.
The initial histological study concluded chronic colitis with the presence of granulation ulcers, associated with few signs of CMV viral eitopatieum damage and a colonic inflammatory pseudopolyparticle, with pending result for staining.
We also performed PCR for cytomegalovirus (CMV) in blood with 137 copies/mL and negative hemocultives for mycobacterial infections.
Due to the histopathological findings and the initial clinical picture, microorganisms were definitively diagnosed with CMV colitis which added to the abundant diagnosis of colonic cystis type 5 mg/kg. However, the histopathological reaction of this patient was early suspended.
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The patient improved his clinical condition with a clear decrease in liquid stools on the third day and normal stools since the seventh day completing 21 days of cotrimoxazole therapy.
A new CT scan of the abdomen and pelvis showed hepatomegaly associated with multiple focal liver lesions hypodense inflammatory aspect, less than 10 mm, possibly in the context of hepatitis along with retroperitoneal granulomatous and retroperitoneal granulomatous polyposis.
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Finally, the diagnosis of P. jiroveci pneumonia and extrapulmonary pneumocystosis with colon involvement was made.
The patient was discharged after one month without diarrhea, malaise and in good general condition.
ART and secondary anti-Pneumocystis prophylaxis with cotrimoxazole were maintained.
Subsequently, the subsequent outpatient follow-up showed weight gain, absence of fever and diarrhea, and undetectable viral load in blood.
