A 58-year-old male patient from Santiago del Estero, Agentina, seropositive for HIV without complying with the antiretroviral treatment, was admitted to the Hospital Santín Aires in August 2010 with a constitutional syndrome.
The patient had been diagnosed with cystis jiroveci pneumonia earlier, with a weight loss of 10 kg and a CD4 lymphocyte count of 70 cc/mm3.
On physical examination it was found that the patient was wet, suffered a headache of mild intensity, holocrane, with no neurological focus.
Abdominal palpation evidenced a painless blade abdomen and no visceromegaly or adenopathy were detected.
In the oral cavity, whitish lesions were observed in the tongue.
The patient was eupneic, with good bilateral airflow and no noises.
He had normal heart sounds and free silences.
Blood pressure was 110/70 mm Hg, heart rate 96 beats per minute, respiratory rate 18 cpm, body temperature 2°C, oxygen saturation 96% (FiO2 0.21):
His body weight was 62 kg, his height 1.75 mts and BMI 20.
Laboratory tests showed a marked increase in LDH of 4,532 IU/L (VN: 480 IU/L) for iron deficiency anemia.
The CD4 lymphocyte count was 31 cells/mm3.
Chagas serology (IFI and blood agglutination) was non-reactive.
Studies for Epstein (VEB) virus IgG (+) IgM (-), cytomegalovirus (CMV) IgG (+) IgM (-) and Toxoplasma gondii IgG (+) IgM (-).
The serology for hepatitis B and C was Ag HBs (-) and anti HCV (-) respectively.
VDRL was non-reactive.
Chest computed axial tomography (CAT) and radiographic images revealed signs of centrilobular emphysema and dispersed peribronchial opacities, probably of inflammatory origin, without frank consolidation, of nonspecific nature.
The electrocardiogram revealed the presence of sinus tachycardia, with no changes compared to previous tracings.
In the direct CSF examination no cells were observed, and the physicochemical study yielded the following results: glucose 50 mg/dL for blood glucose 110 mg/dL, chlorine 116 34.5 mg/L, proteins:
The Chinese ink test for Cryptococcus spp was negative.
The study of bronchoalveolar lavage revealed the following data: 130 cells/mm3 with 82% alveolar macrophages, 16% lymphocytes and 2% neutrophils.
The bacilloscopic studies and cultures for common microorganisms were negative.
Toluidine blue staining for P. jiroveci was negative.
In September 2010, she had an in-hospital pneumonia of unknown etiology, documented by a chest X-ray.
Blood cultures were negative.
Antibiotic therapy was initiated with piperacillin/ tazo, vancomycin and polymyxin.
Bone marrow biopsy revealed hemophagocytic syndrome secondary to HIV, CMV and EBV.
The qualitative PCR for CMV and EBV was positive.
The patient was treated with etoposide, dexamethasone and foscarnet.
Skin biopsy of red-vine maculopapular lesions revealed Kaposi's sarcoma.
The patient was admitted with nasal septum deviation and a necrotic lesion.
The CT of the facial mass showed the absence of middle turbinate and a biopsy of the lesion allowed to diagnose mucormycosis that was treated with liposomal amphotericin and endoscopic surgical debridement of the lesions existing in the nasal cavity.
Due to the presence of pleural effusion, a prevalent hypersensitivity reaction was performed, obtaining a yellowish-white deposit fluid.
The cell count was 70 ccs/m3 (neutrophils 42%, lymphocytes 55%, monocytes 3%).
Cytological examination revealed the presence of mobile trypomastia-gotes of T. cruzi.
The diagnosis was confirmed by median Giemsa and Papanicolaou staining.
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Chemical examination showed glucose: 237 mg/dl, protein 0.4 gr/l.
The pleural fluid culture was negative.
The direct method of Strout revealed the presence of abundant quantities of mobile trypomastigotes.
The next day the patient died due to non-traumatic cardiorespiratory arrest (November 2010).
