Medical Inspection – Health Blog

A 23-year-old male homosexual smoker was well until Jan 22, 1988 when he presented with diffuse PCP Symptomatic and radiographic resolution followed standard therapy. Zidovudine and prophylactic aerosolized pentamidine (150 mg every two weeks via a Respigard II nebulizer) were taken for two months. Four months later, recurrent diffuse PCP was treated with aerosolized pentami­dine (300 mg/day) for 21 days. Again, prophylactic aerosolized pentamidine therapy was instituted.

On Sep 28, 1988, the patient developed a right-sided pneumo­thorax with underlying cystic infiltrates (Fig 1). The infiltrates persisted after chest tube insertion, and bronchoscopy samplings from these areas disclosed PCP Intravenous pentamidine therapy was begun, the pneumothorax resolved, and the chest tube was removed five days later. Twelve days later, a complete right pneumothorax occurred. The patient requested palliative care and died ten days later.

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Pneumocystis carinii pneumonia (PCP) occurs in approx­imately 70 percent of patients with the acquired im­munodeficiency syndrome (AIDS). Its typical radiographic presentation is of bilateral diffuse interstitial infiltrates. Pneumothorax as a complication of AIDS-related PCP has been reported only 15 times.

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The skin is the most commonly affected organ system in disseminated disease. Skin eruptions con­sist of verrucous granulomas, subcutaneous abscess, and indolent ulcers. Verricous lesions are commonly found on the face and nasolabial folds. Several lesions found together may suggest a more malignant course of disease. These lesions initially show epithelial thickenings and grow to resemble common warts. Occasionally, microabscesses form and caseating ne­crosis may occur. Spores are found in the tissue and in multinucleated giant cells. Abscesses are usually not tender, warm, or erythematous, and they are usually seen under the arm and on the back or hip. The abscesses usually have a necrotic center sur­rounded by a granulomatous infiltrate of lymphoid cells, plasma cells, epithelial cells, and giant cells. Fungal spores are abundant in these lesions. Chronic ulcers can form draining sinus tracts and are found over the joints of the foot, ankle, and hands. There are reports of skin as the only organ system affected. These cases are rare in occurrence and are thought to be due to direct innoculation of the skin in laboratory personnel.

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Coccidioidomycosis is a geographically limited in­fection with a wide spectrum of illness, ranging from mild, self-limited, and clinically unrecognized infec­tion to widely disseminated and potentially life-threat­ening disease.

Coccidioides immitis is a dimorphic fungus, found in the soil as an arthrospore and in human tissue as a round-walled spherule. It is found in semi-arid cli­mates with short, intense rainy seasons, such as central California, Arizona, West Texas, New Mexico (the Lower Sonoran life zone), Mexico, and Central and South America. Except for rare cases of direct skin innoculation, infection in humans is by inhalation of the highly infectious arthrospores. Infectivity is en­hanced by dry and windy conditions or activity that stirs up the soil (construction, archaeologic digging, and agricultural work). While infection is most com­mon in these endemic areas, cases have been reported thousands of miles away, presumably through contam­inated fomites. The diagnosis should be considered even in nonendemic areas.

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A21-year-old black man, a nonsmoker previously in good health, presented to the Letterman Army Medical Center Pulmonary Service after six weeks of nonproductive cough, headaches, fevers, anorexia, and a 4.5 kg (ten pound) weight loss. He denied dyspnea, hemoptysis, chest pain, high risk behavior for human immunodeficiency virus (HIV) infection, or gastrointestinal symptoms. He lived and worked in northern California with recent travel to Korea. He had received a ten-day course of erythromycin without relief of his symptoms.

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Cross-sectional echocardiography is a useful nonin­vasive method for diagnosing both intracardiac and extracardiac masses, including mediastinal cysts and tumors, pericardial cysts and tumors, intra­thoracic neoplasms, and left ventricular pseudoaneu- rysms. Although atelectatic segments of lung are encountered frequently during routine echocardio­graphy studies, this entity has not been described well in the literature. Furthermore, these lung masses are usually distinctly separate from the heart and are easily recognized as free-floating, brightly reflective, echo-dense objects. In the present unique series of patients the atelectatic segments appeared to be adherent to the heart, which rendered the initial diagnosis of the mass somewhat more difficult. Indeed, in two of the patients (patients 1 and 2) an extramural cardiac tumor was considered initially, based on the following constellation of findings: the echo-dense mass appeared to be adherent to the heart from the posterolateral to the inferoposterior aspect of the left ventricle; the mass moved synchronously with the heart; the mass was contiguous with hypokinetic segments of the ventricle, which suggested the possi­bility of myocardial injury secondary to tumor infiltra­tion; there was no clear-cut pericardial stripe between the mass and the ventricular wall in any of the tomographic views; the initial admitting chest roent­genogram did not suggest the presence of coexisting pulmonary atelectasis. To the best of our knowledge, the present case reports represent the first description of an atelectatic lung segment mimicking an extracar­diac mass.

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