A 45-Year-Old Man With Shortness of Breath, Cough, and Fever

Christine Kim, MD; Harold Moskowitz, MD


April 17, 2020

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 45-year-old man with a history of HIV infection presents to the emergency department with progressive shortness of breath and dyspnea on exertion for the past month. He recently developed a cough that is productive of white sputum. Today, he awoke with a temperature of 101.0°F (38.3°C). The patient reports no chest pain, hemoptysis, orthopnea, paroxysmal nocturnal dyspnea, palpitations, or lower-extremity swelling. He developed thrush in the previous 1-2 weeks and has also developed anorexia, with a 20-lb weight loss, over the past 3 months.

The remainder of his review of systems is negative. He does not report any recent travel or sick contacts. He has taken no medications recently and elected to stop his HIV therapy regimen 10 years ago because of the adverse effect of severe diarrhea. The patient does not smoke, consume alcohol, or use illicit drugs. He is sexually active with 1 partner and uses condoms inconsistently. The patient has no known drug allergies.

Physical Examination and Work-up

Upon physical examination, the patient's temperature is 101.0°F (38.3°C) tympanic. His pulse rate is 136 beats/min, with a regular rhythm. His blood pressure is 100/70 mm Hg. The patient's respiratory rate is 30 breaths/min, with an oxygen saturation of 76% while breathing room air. In general, the patient is cachectic and dyspneic. He has dry mucous membranes, with removable white plaques throughout the oropharynx. The remaining head and neck examination is normal. Coarse bibasilar crackles are present on auscultation. His chest is nontender on palpation, is resonant to percussion, and expands symmetrically. Except for tachycardia, cardiac examination findings are normal.

The abdominal and neurologic examinations are unremarkable. The patient has no cyanosis, clubbing, or edema of the extremities. His skin is warm, dry, and free of lesions or rashes. He has no palpable lymphadenopathy.

An electrocardiogram reveals sinus tachycardia. The patient's arterial blood gas is consistent with respiratory alkalosis and hypoxia. A chest x-ray reveals diffuse, bilateral increased interstitial markings, and CT angiography (CTA) of the chest demonstrates diffuse ground-glass opacities without lymphadenopathy or pulmonary embolus (Figures 1 and 2).

The white blood cell count is 5.2 × 103/μL. The CD4 lymphocyte count is 38 cells/μL. The result on quantitative HIV-1 RNA polymerase chain reaction (PCR) is 1,710,000 copies/mL. Routine blood and urine cultures are negative. An induced sputum specimen is sent for analysis.


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