Female, 42 years old.
Mandate 8 months with recurrent herpes in mouth
She was admitted due to a 2-month history of dry cough in the accesses and rapidly progressive dyspnea.
In addition, bilateral chest pain, fever up to 39oC and weight loss of 14kg.
Herpetic lesion recurrence caused dysphagia and odynophagia.
Physical examination revealed whitish plaques in the oropharynx; chest examination revealed decreased breath sounds and fine rales.
At room air oxygen saturation was 86%.
The report of arterial oxygen saturation with 70% supplemental oxygen pH was: 7.30, pCO2 40.5mmHg, pO2 132mmHg, HCO3 19.5mmol/l, base excess -5.8mmol/l.
Positioning Index (IO) 188.
Laboratory tests at admission include: lymphopenia of 600 cells/mm3, Hb 11.8gr/dl, lactic dehydrogenase of 971UI/l and albumin 3.3gr/dl.
Chest X-ray showed bilateral patchy opacities with delustrated glass and pneumomediastinum, so the differential diagnosis included immunosuppression associated with HIV and P. jirove pneumonia.
The analysis for HIV by ELISA was POSITIVO, confirmed by Western Blot.
Bronchoscopy with transbronchial biopsy and bronchoalveolar lavage (BAL) was performed.
Histopathological study is reported in Figure 1.
She received treatment with Trimethoprim/Syndromethoxasol and Prednisone at a reduction dose for 21 days.
1.
On the 7th day of treatment she presented respiratory deterioration and OI decreased to 110, so she was admitted to the intensive care unit in a state of shock and support with invasive mechanical ventilation.
At admission, laboratory tests showed leukocytes of 24,300cells/mm3, Hb 10.8gr/dl, lactic dehydrogenase 2033UI/l and albumin of 2,26gr/dl respectively.
In the following 24h, the patient developed massive hemoptysis (volume 250ml).
Describes the Hb value to 6gr/dl, the OI decreases to 106 and is supported by invasive mechanical ventilation.
A 10mmHg POAP was measured by Swan-Ganz.
The chest X-ray is shown in Figure 2A.
The patient underwent BAL whose pathology study confirmed the presence of recent and active alveolar hemorrhage.
In addition, CMV infection was documented by rt-PCR and treatment with Ganvir 350mg/d was initiated for 14 days.
1.
The patient had a good evolution, improved OI up to 277, with removal of invasive mechanical ventilation 9 days after the event.
After 37 days she is discharged home.
During follow-up, the CD4 count was 109cells/μl and the viral load was <40copies/μl.
