Case 2: A 40-Year-Old with Fever and Respiratory Symptoms

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Authors: David H. Spach, MD
Joel E. Gallant, MD, MPH

Case last updated: April 5, 2007

A 40-year-old woman presents for evaluation of fever and respiratory symptoms. She was diagnosed with HIV infection 8 years ago and has intermittently received care for her HIV disease. She was last seen 6 weeks ago and had a CD4 count of 135 cells/mm3 and an HIV RNA of 53,000 copies/ml. Trimethoprim-sulfamethoxazole (Bactrim, Septra) was prescribed at that time, and she was scheduled to follow-up 1 week later to discuss starting antiretroviral therapy. She did not return for the follow-up appointment and she now presents with a 1-2 week history of fever, fatigue, non-productive cough, and dyspnea on exertion. She admits that she did not take any of the trimethoprim-sulfamethoxazole. Her examination shows a respiratory rate of 20. Room air resting O2 saturation was 91%, and her arterial blood gas shows a pH of 7.48, a CO2 of 29 mm Hg, and a pO2 of 68 mm Hg. The chest radiograph shows bilateral opacities with an increase in interstitial markings (Figure 1 and Figure 2). She has no known drug allergies.

Which one of the following statements is most likely TRUE?

	The clinical picture and chest radiograph are most consistent with a diagnosis of Mycoplasma pneumonia, and the patient should receive amoxicillin-clavulanate (Augmentin).
	The clinical history and chest radiograph are most consistent with cytomegalovirus pneumonitis and the patient should immediately receive intravenous ganciclovir (Cytovene).
	The clinical history and chest radiograph are most consistent with a diagnosis of Pneumocystis pneumonia. The patient should be started on high-dose trimethoprim-sulfamethoxazole plus corticosteroids and should undergo a work-up to establish the diagnosis.
	The clinical history and chest radiograph are most consistent with a diagnosis of diffuse pulmonary Mycobacterium avium complex infection and the patient should receive clarithromycin (Biaxin) plus ethambutol (Myambutol).

Figure 1
Figure 2