Question
A 36-year-old male presents with fever, dry cough, and dyspnea for two weeks. He has a history of HIV, and he does not take any medications. Temperature is 38.6 C (101.5 F), the pulse is 90/min, blood pressure is 130/80 mm of Hg, and respirations are 28/min. Pulse oximetry shows an oxygen saturation of 84%. Chest auscultation reveals diffuse crackles in both lungs. Serum lactate dehydrogenase is 350 U/L. Chest x-ray shows bilateral diffuse interstitial infiltrates. Gram staining and culture of the sputum do not reveal any organisms. Which of the following is the next best step?
| A. |
Bronchoscopy with bronchoalveolar lavage
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| B. |
Examination of stool or respiratory excretion for eggs or worms
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| C. |
Acid-fast stain of stool
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| D. |
Urine antigen test
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Show Answer
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Correct Answer � A
Explanation
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Ans. a. Bronchoscopy with bronchoalveolar lavage
Pneumocystis pneumonia (PCP) can present in patients with HIV as fever, cough, and dyspnea. Chest x-ray shows bilateral diffuse interstitial infiltrates. Pneumocystis jiroveci is a unicellular fungus that causes diffuse interstitial pneumonia in immunocompromised hosts. PCP pneumonia rarely, if ever, occurs in healthy individuals.
Diagnosis is done by the detection of the organism in the sputum with microscopy after silver staining.
Sometimes, induced sputum may not yield organisms. In such cases, bronchoscopy should be done to collect a sample with bronchoalveolar lavage.
Microscopy of the collected specimen is stained with methenamine silver stain or fluorescent antibody. It will reveal disc-shaped yeasts (“cup-in-saucer” appearance).
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