Holoinspiratory Wheezing in a 46-Year-Old HIV-Seropositive Man - QUIZ

Figure 1. Computed tomographic scan of the chest revealing multiple cavitary pulmonary lesions (A) and tracheal subocclusion (B, arrow). C, Inset showing endoscopic appearance of tracheal subocclusion caused by exophytic lesions extending over 4 cartilaginous rings. Air passage was possible only through a small hole (arrow).

A 46-year-old Italian man seropositive for human immunodeficiency virus (HIV) type 1 was admitted to our department with a 3-month history of nonproductive cough and progressively worsening dyspnea. The patient was a former heroin addict with liver cirrhosis caused by hepatitis C virus and previously treated visceral leishmaniasis and latent syphilis. He was on antiretroviral treatment consisting of emtricitabine, tenofovir, and fosamprenavir with an undetectable HIV load and a CD4 Tlymphocyte count of 180 cells/µL. On hospital admission, the patient was afebrile but short of breath at rest, with a heart rate of 110 beats per minute, respiratory rate of 35 breaths per minute, and oxygen saturation of 80% on room air. Physical examination revealed holoinspiratory wheezing. His oral cavity was unremarkable. Arterial blood gas showed an arterial pH of 7.48, an oxygen partial pressure of 56 mm Hg, and a carbon dioxide partial pressure of 28 mm Hg while breathing ambient air. A computed tomographic scan of the chest was performed showing multiple bilateral pulmonary lesions, some with a cavitary appearance (Figure 1). Bronchoscopy demonstrated tracheal subocclusion caused by irregular, friable rosy vegetations extending over 4 cartilaginous rings (Figure 1C). Biopsies were obtained (Figure 2). 

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Clinical Infectious Diseases 2014;58(1):78

DOI: 10.1093/cid/cit660