Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors
The patient is a 52 year old African-American man who presented with breathlessness and weight loss over one month along with watery stools during the week prior to admission. He had a history of untreated HIV infection, a CD4 cell count of 5/cmm, oral candidiasis, and peri-rectal HSV infection. The patient reported occasional cough with variable sputum production but denied fever, night sweats, hemoptysis, recent travel, or sick contacts. His risk factor for HIV infection was having sex with other men. The physical was notable for cachexia, normal temperature, blood pressure of 87 mmHg systolic, respiratory rate of 25 bpm, O2 saturation of 89% breathing room air, coarse breath sounds somewhat decreased at the left base, and unrevealing dermatologic exam. Labs showed a WBC of 2k/cmm, 23% bands, albumin 1.8 gm/dL and an LDH of 422 U/L.
CXR and CT are shown below: