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Self-Assessment Questions

Pulmonary Disease

Pulmonary Complications of HIV Infection: Review Questions

May M. Lee, MD


Dr. Lee is a fellow, Section of Pulmonary and Critical Care, Department of Internal Medicine, University of Chicago Hospitals, Chicago, IL.



Choose the single best answer for each question.



Figure 1

Questions 1 and 2 refer to the following case.
A 29-year-old woman with AIDS and a most recent CD4+ cell count of 10 cells/µL is admitted to the hospital with a 1-week history of nonproductive cough, shortness of breath, and dyspnea on exertion. She is only able to walk a room’s length before she needs to rest. She also reports fever, chills, and sweats prior to admission. Highly active antiretroviral therapy (HAART) has been discontinued due to an unknown intolerance and she has not been taking other medications. The patient is emaciated and is in mild respiratory distress. Vital signs are temperature, 103°F; blood pressure, 121/62 mm Hg; heart rate, 127 bpm; respiratory rate, 25 breaths/min; and oxygen saturation, 88% on room air. Head and neck examination reveals a white exudate throughout the posterior oropharynx as well as on her tongue. Cardiovascular examination reveals tachycardia with regular rate and rhythm and no murmurs. Lung examination reveals diffuse crackles with poor air movement throughout. Laboratory examination reveals a normal white blood cell count and basic metabolic panel and a lactate dehydrogenase (LDH) level of 376 U/L (normal, 116– 245 U/L). A chest radiograph is performed (Figure 1) followed by bronchoscopy with bronchoalveolar lavage to confirm the diagnosis.

 

1. What is the most appropriate treatment for this patient?
  1. Amphotericin B
  2. Isoniazid, ethambutol, rifampin, and pyrazinamide
  3. Trimethoprim/sulfamethoxazole (TMP/SMX)
  4. TMP/SMX and prednisone
  5. Vancomycin
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2. Assuming that this patient has never had a prior acute opportunistic infection, which of the following medications should she have been prescribed as prophylaxis?

  1. Azithromycin and fluconazole
  2. TMP/SMX and azithromycin
  3. TMP/SMX, azithromycin, and fluconazole
  4. TMP/SMX and fluconazole
  5. Prophylaxis is not necessary
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3. A 49-year-old African American woman with a history of HIV and type 2 diabetes mellitus presents to the emergency department (ED) with a 2-week history of general malaise, fever, headache, cough, and dyspnea. She also notes gradual onset of right lateral chest pain that is sharp, nonradiating, relieved with acetaminophen, and exacerbated by cough and deep breathing. The patient appears ill and is in mild distress. Her vital signs are temperature, 103°F; heart rate, 111 bpm; respiratory rate, 18 breaths/min; blood pressure, 129/88 mm Hg; and oxygen saturation, 97% on room air. Cardiovascular examination reveals tachycardia with a regular rhythm and no appreciable murmurs. Lungs are clear to auscultation bilaterally. She has no chest wall tenderness or neck stiffness. The neurologic examination is grossly intact; she is alert and oriented. A chest radiograph shows a right-sided solitary pulmonary nodule with mediastinal widening in the right paratracheal region. Computed tomography shows an ill-defined subpleural nodule in the right upper lobe with soft tissue masses seen in the right paratracheal, subcarinal, hilar, and para-aortic regions. Bronchoscopy is performed with transbronchial needle biopsy of the right paratracheal and subcarinal masses. Methenamine silver stain of biopsied tissue reveals numerous narrow-based, budding extracellular yeasts of Cryptococcus neoformans within the alveolar spaces. What laboratory data should be collected next?

  1. Cryptococcal subgroup typing
  2. Lumbar puncture
  3. Serum cryptococcal antigen titers
  4. Sputum evaluation
  5. Transthoracic needle biopsy of the right upper lobe nodule
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Figure 2

Questions 4 and 5 refer to the following case.
A 34-year-old homosexual man with AIDS and a most recent CD4+ cell count of 0 cells/µL presents to the ED with a 2-week history of pleuritic chest pain, shortness of breath, and dry cough. He reports that shortness of breath occurs with minimal exertion. He denies fever or chills but admits to a 10-lb weight loss over the past 4 months. On admission, his temperature is 97°F, heart rate is 103 bpm, blood pressure is 124/81 mm Hg, respiratory rate is 18 breaths/min, and oxygen saturation is 98% on room air. Head and neck examination is significant for a nodular pigmented lesion on his hard palate. Cardiovascular examination reveals tachycardia with a regular rhythm and no murmurs. Lung examination discloses crackles in all fields with both end-expiratory and inspiratory wheezes. Skin examination shows multiple plaque-like hyperpigmented lesions on his legs, back, and arms. A chest radiograph is performed (Figure 2). Bronchoscopy reveals extrinsic compression throughout the tracheobronchial tree with fresh blood in the airways and no purulent discharge.

 

4. What is the most likely cause of this patient’s symptoms and radiographic findings?
  1. Mycobacterium tuberculosis
  2. Human herpesvirus 8 (HHV-8)
  3. Pneumocystis jiroveci
  4. Streptococcus pneumoniae
  5. Epstein-Barr virus
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5. Incidence of this patient’s illness in the United States has decreased as a result of which of the following?

  1. Azithromycin prophylaxis
  2. Corticosteroids
  3. HAART
  4. TMP/SMX prophylaxis
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