Dyspnea in a 23 year old male

Case:
A 23 year old male presented on February 16 with two months of dyspnea. On arrival is oxygen saturation was 77% on room air. Josh and I were called to the bedside for evaluation. On further questioning he admits to two months of this progressively worsening difficulty breathing and also 2-3 loose stools daily. He's had significant weight loss as well, approximately 5kg over the last couple of weeks. He has had a poor appetite. He denies any drug or alcohol use. He is not a smoker. He has no lung problems.

On exam the patient is very thin and in obvious respiratory distress with 2-3 word dyspnea. His oxygen saturation improved with oxygen via nasal cannula and he was around 96% on 3 liters via nasal cannula. His lungs were remarkably clear, with slightly decreased lung sounds in the left lower lung. He had no lymphadenopathy, no jaundice, no oral or skin lesions, and no abdominal distension or tenderness. He had no lower extremity swelling. He was febrile to 39 degrees celsius and tachycardic into the 140s. He was not hypotensive. So in terms of sick vs not sick, this patient was sick.

After the initial exam, and once his family had exited the room briefly, he admits to being HIV positive. He was diagnosed about one year ago but has not taken any anti-retrovirals. He likely contracted the illness from his recent ex-boyfriend who is also HIV positive.

I looked at Josh, "well this is more interesting now...". And obviously this patient is potentially very sick. An chest xray was obtained which showed the above findings, diffuse groundglass opacities in bilateral lungs without a clear consolidation. The classic finding of PCP (pneumocystis carinii or pneumocystis jirovecii pneunomia) is a "batwing" appearance, with fullness in the perihilar region of both lungs, extending peripherally. His chest xray certainly fit this description.

While PCP is very high on the differential for this patient, he is also at risk for community acquired pneumonia, tuberculosis, fungal respiratory infections, etc. We started him on IV ceftriaxone and azithromycin orally for community acquired pneumonia as well as Bactrim for PCP. We hydrated him with IV fluids, sent off labs (including a CD4 count), and treated his fevers with tylenol and ibuprofen. Surprisingly, his labs looked great. CD4 count is still pending. It's amazing how resilient the human body can be.

Luckily the patient turned around quickly and is doing very well today. Patients with PCP can apparently decompensate fast, so I'm relieved by his recovery so far. He remains in isolation as we rule him out for TB, however he has not been able to produce enough sputum to check his sputum, which I suppose is a good sign since he's improving without TB medicines. My hope is that we can convince him to take anti-retrovirals, as he has expressed concerns about the side effects of these drugs thus the reason he has not been taking them. Hopefully this hospitalization has scared him enough to convince him that the benefits far outweigh the risks.