A 27-year-old woman with active polytoxicomaman who, 15 days before admission, began with dry cough, progressive dyspnea, fever, asthenia, anorexia, nausea and vomiting.
She had a history of newly diagnosed HIV infection, unknown immunological and virological parameters.
Examination at admission showed cachexia, 40 breaths/min, 120 beats/min. TA:110/60 mm Hg, muguet, acropachis, bilateral supraclavicular systolic lymphadenopathy cm.
The rest of the somatic and neurological examination were normal.
At admission, the following complementary tests were performed: Hb 11.3 g/dL, 6900 leukocytes/μL (79% segmented, 14% lymphocytes), 682,000 platelets/μL; sodium 119 mmol/L, LDH 603 IU.
Arterial gas at admission: pH 7.54, pCO2 34.8 mm Hg, pO2 73.4 mmHg.
A right anterior mediastinal mass compressing and displacing the trachea and bilateral alveolar-interstitial infiltrate is observed in the chest plaque.
Subsequently, abdominal ultrasound and thoracic, abdominal and pelvic CT were performed in which bilateral axillary lymphadenopathies of less than one cm were observed, a large mediastinal mass compressing the interstitial tracheal pattern and the vena cava resolution were small.
Transthoracic echocardiogram showed no abnormalities.
Treatment was initiated with cotrimoxazole, levofloxacin and amphotericin-B, despite which she developed progressive respiratory failure requiring mechanical ventilation.
An improvement in respiratory failure is observed during the following days, allowing the removal of mechanical ventilation.
Subsequently, the patient developed generalized tonic-clonic seizures followed by left hemiparesis. Cranial MRI revealed a thick wall mass and a hypodense center of 4 cm in diameter encruciment of the right temporal lobe.
Treatment with diuretics is added to treatment with pyrimidine, folic acid and phenytoin, which are withdrawn three weeks later due to the absence of clinical improvement and reduction of the intracranial lesion.
FNAC and supraclavicular lymph node biopsy were performed and reported as metastasis of an undifferentiated malignant tumor of epithelial origin.
Later the following results were received: CD4+ lymphocytes: 440/mL, HIV viral load: 25,000 copies/mL, normal alpha-fetoprotein and b-HCG: 650 mIU/mL (normal).
Microbiological studies in blood, urine, sputum, broccoaspirate and lymph node puncture were negative for bacteria, mycobacteria and fungi.
Respiratory sample stains were negative for P. carinii (P. jiroveci).
Serology for Toxoplasma, hepatotropic virus and RPR were negative; cryptococcal antigen was negative.
1.
Diagnosis and evolution: Initially the diagnosis of diffuse pneumonia presumptively by P. carinii (P. jiroveci) and probable disseminated lymphoma with mediastinal, cerebral and intestinal involvement was made.
After receiving the results of lymph node biopsy and tumor markers (alphafetoprotein and ß-HCG), a definitive diagnosis is made: extragonadal germ cell tumor with supraclavicular and midbrain lymph node involvement.
The patient is proposed to perform a tumor extension study and start treatment with polychemotherapy, which rejects, despite explaining that the high chemosensitivity of the tumor made it potentially curable.
The patient died in another center several weeks after discharge.
