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Old 01-20-2013
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Question HIV Case Presentation

A 35-year-old HIV-positive man (CD4+ cell count 150/mm³) is seen in the emergency department with right-sided chest pain. The patient has become progressively dyspneic over the past few days. Suddenly, 30 minutes ago he noticed a sharp pain in his chest associated with shortness of breath. His temperature is 37.7° (99.9°F), blood pressure is 128/84 mm Hg, pulse is 102/min and regular, respiratory rate is 25/min, and oxygen saturation is 90% on room air. Physical examination reveals diminished right-sided breath sounds and hyperresonance. Jugular venous distention is 5 cm and there is no tracheal deviation. ECG shows sinus tachycardia. X-ray of the chest shows a right-sided pneumothorax occupying approximately 10% of the right thoracic cavity. Which of the following most likely caused this patient’s presentation?
(A) Intravenous drug use
(B) Kaposi’s sarcoma
(C) Mycobacterium tuberculosis
(D) Pneumocystis jiroveci pneumonia
(E) Toxoplasmosis
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Old 01-20-2013
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Pneumocystis jiroveci pneumonia


Pneumocystis>>>>>Pneumothorax, pneumatoceles
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Old 01-20-2013
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(D) Pneumocystis jiroveci pneumonia
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Old 01-21-2013
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Medline ® Abstract for Reference 4

of 'Pneumothorax in HIV-infected patients'

4

PubMed


TI
Pneumothorax in AIDS.

AU
Sepkowitz KA, Telzak EE, Gold JW, Bernard EM, Blum S, Carrow M, Dickmeyer M, Armstrong D

SO
Ann Intern Med. 1991;114(6):455.


OBJECTIVE: To determine risk factors for the development of pneumothorax in patients with the acquired immunodeficiency syndrome (AIDS).
DESIGN: Prospective cohort study.
SETTING: Tertiary care center.
PATIENTS: Of 1030 patients with AIDS who were followed at Memorial Sloan-Kettering Cancer Center between 1 January 1980 and 30 September 1989, 20 (2%) developed pneumothorax that was unrelated to trauma or a pulmonary procedure.
RESULTS: Of 20 patients with AIDS who presented with pneumothorax, 19 had compelling evidence of concurrent Pneumocystis carinii pneumonia. Using bivariate analysis, patients receiving aerosol pentamidine prophylaxis (relative risk, 17.6) and those with a history of P. carinii pneumonia (relative risk, 14.5) were more likely to develop pneumothorax. By Mantel-Haenszel stratified analysis, aerosol pentamidine use was a statistically significant risk factor independent of a history of P. carinii pneumonia. The pneumothorax-related mortality rate was 10% and there was considerable morbidity.
CONCLUSIONS: Patients with AIDS at the highest risk for developing pneumothorax are those with a history of P. carinii pneumonia who are receiving aerosol pentamidine prophylaxis but who nevertheless develop P. carinii pneumonia. The benefits of aerosol pentamidine prophylaxis in these patients far outweigh this risk. Pneumocystis carinii pneumonia should be considered as the most likely diagnosis in any patient with AIDS who develops a pneumothorax.


AD
Memorial Sloan-Kettering Cancer Center, New York, New York.

PMID
1994791
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Old 01-21-2013
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Sepkowitz KA, Telzak EE, Gold JW, et al. Pneumothorax in AIDS. Ann Intern Med 1991; 114:455

CONCLUSIONS: Patients with AIDS at the highest risk for developing pneumothorax are those with a history of P. carinii pneumonia who are receiving aerosol pentamidine prophylaxis but who nevertheless develop P. carinii pneumonia. The benefits of aerosol pentamidine prophylaxis in these patients far outweigh this risk. Pneumocystis carinii pneumonia should be considered as the most likely diagnosis in any patient with AIDS who develops a pneumothorax.
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Old 01-21-2013
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The correct answer is D. Pneumothorax is an
uncommon but potentially fatal complication
of HIV believed to occur in 2%–6% of HIV patients
at some point during their infection.
More than 80% of the cases of pneumothorax
in HIV patients occur in conjunction with
Pneumocystis jiroveci pneumonia. Extensive tissue
invasion within the alveolar interstitium is
common in severe cases, and may be an important
factor in causing necrosis and subsequent
pneumothorax. Patients with pneumothorax
present with the sudden onset of
unilateral pleuritic chest pain and dyspnea.
Physical examination can reveal decreased or
absent breath sounds, hyperresonance, and decreased
tactile fremitus on the affected side.
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Infectious-Diseases, Internal-Medicine-, Pulmonology-, Step-2-Questions

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