[Solved]: Case 4: A 48-year-old male went to the ER with a…

Case 4: A 48-year-old male went to the ER with a persistent fever (38.8deg C) and a productive cough for four weeks. He indicated that he had been on a mission trip in the Hunan province of China for several months and had noticed weight loss (10 kg over 3 months), night sweats, and general weakness. He had originally thought it was due to his new environment until he also developed skin lesions on his face and trunk. The attending physician confirmed multiple umbilicated papules resembling molluscum contagiosum on the skin and noted rales over both lungs and tachypnea (RR: 26/min). The patient informed the nurse that he had been diagnosed with HIV approximately 8 years ago but had not been compliant with ART treatment for the past two years. She checked his CD4 T cell level and the numbers (20 cells/μL) were consistent with progression to AIDS. Additional blood work showed pancytopenia, an elevated serum lactate dehydrogenase (LDH) level, markedly elevated CRP and an HIV viral load of >100,000 copies/mL. Bilateral diffuse infiltrates were seen on a chest X-ray and a follow up chest CT showed multiple small nodular lesions and interstitial thickening. Cultures of both sputum and blood showed the growth of small broom-like structures and a skin biopsy revealed intracellular yeast forms. Antifungal therapy was scheduled in two phases: induction and consolidation. Intravenous amphotericin B deoxycholate (0.7 mg/kg/day) was given for two weeks followed by oral itraconazole (200 mg twice daily) for ten weeks. ART was reinitiated two weeks after starting antifungal therapy to prevent immune reconstitution inflammatory syndrome (IRIS). The patient demonstrated significant clinical improvement by the end of the induction phase, with resolution of fever and cough. Skin lesions began regressing after 4 weeks of treatment. Follow-up imaging after 12 weeks showed marked improvement in pulmonary nodules. The patient continued maintenance therapy with itraconazole (200 mg/day) and regular ART, achieving a CD4 count of 150 cells/μL within six months. Case 4 Etiology: