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Case 161

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A 39-year-old male patient has a history of a 3-month intense and diffuse abdominal pain. Two months ago, developed a progressive dyspnoea at rest, associated with a feeling of increased body temperature (not measured), chills, vomiting, sweating and morning coughing. There was a concomitant weight loss of 22 kg. There are reports of exposure to pesticides for five months without use of personal protective equipment. On examination, he was emaciated, dyspnoeic and sweaty, breath sounds were diminished at both hemithoraces bases, and respiratory rate was 2 breaths per minute, on supplemental oxygen by face mask. Rapid test for identification of antibodies to human immunodeficiency virus (HIV) was positive.

Considering images provided and clinical history, which is the most likely diagnosis?

a) Bacterial Pneumonia

25%

b) Pneumocystis pulmonary infection

25%

c) Hypersensitivity Pneumonitis

25%

d) Pulmonary Tuberculosis

25%
   

Image Analysis

Images 1 e 2: Computed tomography (CT) of the chest showing diffuse opacity with ground-glass attenuation affecting the lung parenchyma bilaterally (red area). The ground-glass area is characterized by a homogeneous increase in attenuation without obscuring the limits of vascular structures that may be caused by thickening of alveolar interstitium, thickening of alveolar walls or presence of fluid or cells in alveolar spaces.

Highlights

  • -HIV-infected patients.

  • -Insidious onset, significant weight loss, significant tachydyspnoea, non-productive cough, chills, fever syndrome.

  • -Laboratorial exams show no specific changes, however, the CD4 + count is usually less than 250/mm3.

  • -Chest CT with diffuse opacity in a ground-glass attenuation pattern affecting the lung parenchyma bilaterally.

  • -Important differential diagnoses are infections caused by Paracoccidioides brasiliensis and Histoplasma capsulatum, especially in endemic areas.

  • References

  • -Ambrósio AVA, Camelo CCS, Barbosa CV, Tomazatti FG, Brazões FAS, Veloso JM, Rodrigues GV, Rodrigues LF, Oliveira PID, Aguiar RA, Siqueira VS, Jardim VB, Gontijo VAC, Cruz SG, Siqueira WC, Pedroso ERP. Paracoccidioidomicose (doença de Lutz-Splendore-Almeida) - manifestações clínicas. Rev Med Minas Gerais; 241:67-73, Jan/Mar, 2014

  • -Ambrósio AVA, Camelo CCS, Barbosa CV, Brazões FAS, Rodrigues LF, Aguiar RA, Siqueira VS, Jardim VB, Moura ACL, Santos LS, Cruz SG, Siqueira WC, Rocha-Silva F, Caligiorne RB, Góes AM, Pedroso ERP. Paracoccidioidomicose (doença de Lutz-Splendore-Almeida): tratamento, duração do tratamento, recidiva, reação paradoxal, prognóstico, profilaxia. Rev Med Minas Gerais; 241:74-80, Jan/Mar, 2014

  • -Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Doenças Infecciosas e parasitárias: guia de bolso/Ministério da Saúde – 8 ed. rev. – Brasília: Ministério da Saúde. 2010. Parte III, cap. 1, pág. 75-89;

  • -Pedroso ERP, Oliveira RG. AIDS. In Pedroso ERP, Oliveira RG. Blackbook Clínica Médica. 1a edição. Blackbook Editora. Belo Horizonte. 2007. Pág. 674-687;

  • -Pedroso ERP, Serufo JC. Pneumonias. In, Pires MTB, Pedroso ERP, Serufo JC, Braga MA. Emergências  Médicas. 1a edição – Rio de Janeiro: MedBook, 2014. Cap. 52, pág. 569-577;

  • -Ravetti CG, Greco DB, Pedroso ERP. Síndrome de Imunodeficiência Adquirida. In, Pires MTB, Pedroso ERP, Serufo JC, Braga MA. Emergências  Médicas. 1a edição – Rio de Janeiro: MedBook, 2014. Cap. 58, pág. 629-665.

  • -Silva, I. Tórax – São Paulo: Colégio Brasileiro de Radiologia, 2010. Cap. 15, pág. 299-312; cap. 18, pág. 335- 351; cap. 24 , pág. 421-431.

  • -Veronesi, R, Diament D, Focaccia R, Ferreina, MS, Siciliano RF. Tratado de Infectologia. 4ª edição – São Paulo: Atheneu, 2010. Volume 2, parte VIII, cap. 87, pág. 1577-1591.

Supervisors

Enio Roberto Pietra Pedroso, specialist in Infectious Disease, Full Professor at the Department of Clinical Medicine at UFMG School of Medicine. E-mail: enio[at]medicina.ufmg.br

José Nelson Mendes Vieira, Radiologist, Professor of the Department of Anatomy and Imaging at UFMG School of Medicine. E-mail: zenelson.vieira[at]gmail.com

Authors

Letícia Horta Guimarães, 6th year medical student at UFMG School of Medicine.

E-mail: leticiahorta[at]gmail.com

Fernando Carrera, 6th year medical student at UFMG School of Medicine.

E-mail: nandocarrera[at]gmail.com

Reviewers

Marina Bernardes Leão, Janaína Chaves, Ana Júlia Bicalho, Luanna Monteiro, Bárbara Queiroz, André Guimarães, Viviane Parisotto.

Translated by

Ana Júlia Bicalho, 6th year medical student at UFMG School of Medicine.

Email: anajuliabicalho[at]gmail.com

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