Breathless, Coughing and Run-down: What's Going On? | Case Study
A new case study in which the patient, a 32-yr-old white male presents to a local free clinic with fatigue, moderate dyspnea, and a persistent and non-productive cough.
"For the past few days I've been feeling run-down. I can't stop coughing and I'm out of breath. It can't be COVID – I already had it a few months ago.”
History of Present Illness
The patient has struggled with homelessness for many years. He visits the free clinic every few months, most recently to be treated for Chlamydia and Gonorrhea after experiencing painful urination and swollen testicles. He states that his symptoms "came on fast.”
General Appearance
Patient is thin and sunburned. He looks more than his stated age, with many wrinkles and burst blood vessels in his nose. His clothing is too large and there is dirt on his pant legs, the creases in his neck and under his fingernails. His hair is long and tangled and in a ponytail. He appears sober and smells of body odor and cigarettes.
Past Medical History
RSV at 6 months
Treated for tuberculosis for 12 months with isoniazid 5 years ago
Perianal ulceration, positive for herpes 4 years ago topically treated with acyclovir and zinc oxide
MVA resulting in multiple herniated discs and fractures to spine 3 years ago
Tested positive for COVID-19 after experiencing mild fever and cough – he got tested when he lost his sense of smell 6 months ago
Chlamydia and Gonorrhea 3 months ago, treated with ceftriaxone and azithromycin.
Family History
No history given
Social History
Homosexual, admits to engaging in unprotected intercourse since the age of 18. He lives on and off with his 60 yo aunt "until she kicks me out.”
He is unemployed and receives social security disability checks for back pain related to the MVA.
He previously had worked for several different gas stations
He smokes at least one pack of cigarettes a day "if I can get them.”
He has a history of alcohol, cocaine, heroin and methamphetamine abuse.
Immunizations
Had tetorifice shot over 10 years ago but can't recall any others. He does have a COVID-19 vaccination card. "When I found out I could win the lottery, I went right in.”
All the tests already mentioned but also I would want to know specifically what areas he beds down in and frequents. Asbestos? Hx of drug use could mean environmentally compromised areas. Emaciated appearance also points me in that direction. Any factories, toxic emissions? Close to a busy road? Sputum Cytology? R/O cancer.. Chest Xray, CAT Scan? Any pulmonary parasites from strange foods or cooking methods? Tidal volume? Blood gases? Definitely a pulmonary consult!
I’m leaning toward a respiratory infection given his respiratory rate and breath sounds. There is no consolidation which points away from pneumonia. Lesions in mouth and cachexia could be thrush and general immunocompromise May be anemia of chronic disease.
Negative COVID test suggests that previous COVID infection may have caused long term pulmonary damage
Specializes in Education, Informatics, Patient Safety.
SECOND FOLLOW UP (final post next week):
Other tests:
Sputum specimen obtained with inhalation of 3% saline by ultrasonic nebulizer:
Methanamine silver stain positive (consistent with Pneumocystis infection)
Monoclonal antibody with immunofluorescence: + Pneumocystis
ABG (normal values)
pH 7.45 (7.35-7.45)
PaO2 69 mmHg (83-108)
PaCO2 30 mmHg (32-48)
SaO2 92% (>95%)
Yes, he’s got pneumonia, but there’s something else going on. What’s causing his oral thrush? What will you treat the pneumonia with given his allergies?
Specializes in Physiology, CM, consulting, nsg edu, LNC, COB.
The pneumocystis and accompanying ABGs are the tip. You don’t want us to post our answers so I won’t, but I gotta say I had this guy pegged at the beginning, seen waaay too many of him before.
The thrush is an opportunistic infection r/t immune deficiency, treat c the usual non-sulfa meds for yeast overgrowth. The fungal pneumocystis pneumonia (PCP) is also opportunistic r/t immune deficiency. Treat the PCP with TMP/Bactrim normally, but he’s allergic to sulfa, so possibly amphotericin if resistant (some advocate for clinda), and oxygen and rest as his A-a gradient is already showing signs of poor gas exchange, borderline resp alkalosis (nl PaCO2 is 35-45) r/t increased resp drive for hypoxia (PaO2 and sats low).
And of course, start treating his underlying condition.
Specializes in Education, Informatics, Patient Safety.
FINAL POST
The diagnosis of pneumocystis pneumonia (fungal pneumonia), oral thrush and his history of unprotected intercourse leads you to test him for HIV.
More lab tests:
CD4 cells 15% (25-65)
CD4 cells/mm3 30 (500-1200)
CD8 cells 28% (10-30)
CD8 cells/mm3 210 (336-780)
CD4/CD8: 0.14 (1.5-2.5)
HIV RNA 70,000 copies/mL
Positive lab test for HIV with both ELISA and Western blot
The patient admits to supplementing his income with sex work. He is treated with fluconazole for the thrush, erythropoietin for anemia, Primaquine 15-30 mg PO PLUS Clindamycin 600 mg IV for the pneumonia. In addition, antiretroviral therapy (ART) will be started to treat AIDS.
Acquired immunodeficiency syndrome (AIDS) is a chronic, possibly life-threatening illness caused by the sexually transmitted human immunodeficiency virus (HIV), though it can also be spread during childbirth or by contact with infected blood. HIV interferes with your body's ability to fight infection and disease by damaging the Helper T/CD4 cells of the immune system. The fewer CD4 T cells you have, the weaker your immune system. AIDS is defined as having a CD4 count below 200.
About 1.2 million people in the US have HIV. About 13 percent don’t know it. It disproportionately impacts people of color, gay, bisexual and other men who have sex with men. In 2019 there were an estimated 34,800 new HIV infections in the US. The CDC recommends that everyone aged 13-64 be tested at least once. Those at high risk should be tested at least annually.
Untreated, HIV typically turns into AIDS in about 8 to 10 years. It’s important to teach those with high-risk behaviors such as having unprotected sex, an STI and use of IV drugs the importance of getting tested for HIV regularly, since catching it before it destroys the immune system can lead to a long and healthy life. For therapy to be successful, patients need counseling and support since ART must be taken as prescribed without missing or skipping doses. Patients also may need help with dealing with the diagnosis as well as with discussing HIV status with future partners.
Signs and Symptoms:
Those infected by HIV can develop a flu-like illness within two to four weeks after the virus enters the body. This illness, known as primary (acute) HIV infection, may last for a few weeks.
Signs and symptoms such as swollen lymph nodes, diarrhea, weight loss, oral thrush, shingles and pneumonia may occur.
Progression to AIDS
Due to antiviral treatments, most people with HIV in the U.S. don't develop AIDS. When AIDS occurs, immune system damage may lead to the development of opportunistic infections or opportunistic cancers. Signs and symptoms may include:
Sweats
Chills
Recurring fever
Chronic diarrhea
Swollen lymph glands
Persistent white spots or unusual lesions on your tongue or in your mouth
Persistent, unexplained fatigue
Weakness
Weight loss
Skin rashes or bumps
Infections and complications common to HIV/AIDS
Pneumocystic pneumonia (PCP)
Candidiasis (thrush)
Tuberculosis
Cytomegalovirus
Cryptococcal meningitis
Toxoplasmosis
Lymphoma
Kaposi’s sarcoma
Wasting syndrome
Neurological complications
Kidney and liver disease
Once a person is diagnosed with AIDS, they can have a high viral load and are able to transmit HIV to others very easily. Without treatment, people with AIDS typically survive about 3 years.
techitalia, EMT-B
18 Posts
covid shot dates and info