A 45 year-old man presented to the ER with 15 months history of cough productive of minimal whitish sputum without frank or streaks of blood, low grade fever, generalized muscle and joint pains. He had no night sweats but had anorexia and 4-6 lbs weight loss in past 6 months. Patient admitted smoking cigarettes (1/2 pack for past 25 years) and marijuana with moderate alcohol consumption. He had three life time sexual partners. He was originally from West Africa and had been in the US for 16 years. PPD and HIV status were unknown. He was a part time car mechanic and was living with wife and 2 kids. There was no past medical, surgical history or known allergies.
On physical examination he had low grade fever (100.3F), tachycardia of 103/min and normal oxygen saturation on room air. There was no lymphadenopathy. He had inspiratory crackles on the right lower lung zone. He had a leukocytosis of 13 K/uL with neutrophilia of 93%. Hemoglobin was 13 gm/dl, MCV was 73 fL and platelets were 198'000/uL. Hepatic profile was significant for protein-albumin dissociation (7.3/2.4). Hepatitis serology was negative for antibodies to Hepatitis A and C, negative HBsAg. Chest X ray showed bibasilar cystic vs. cavity lesions. CT chest with contrast showed ground glass opacities throughout both lungs (Figure 1). Active pulmonary tuberculosis was ruled out. He was treated with Ceftriaxone and Azithromycin for possible community-acquired pneumonia. Rapid HIV test was positive with HIV RNA viral load of 89,000 copies/ml and a CD4 count of 546 cumm (28%). Bacterial and fungal blood cultures were negative. Serologic tests for Aspergillus, Crytpococcus, Echinococcus, Toxoplasma gondii, Leptospira and urine for Legionella and Gonorrhoea were all negative. He was found to have negative RPR but positive TPPA. Considering his young age autoimmune work up was sent for SLE, RA, Sjogren Syndrome, and Wegener's granulomatosis which came back negative. CRP and ESR were elevated (18 mg/dl and 80 mm/hr respectively). Clinical symptoms improved slightly. He underwent VATS (Video Assisted Thoracic Surgery) and tissue histology from right lower and upper lobes specimens showed myxoid intra-luminal material surrounded by fibroblasts and hemosiderin with slight interstitial inflammation consistent with COP (Figure 2). He was started on prednisone at 1 mg/kg body weight once daily with significant improvement in his symptoms. Patient was followed up on outpatient basis. Steroids were tapered off in 8 months time. On his regular office visits his CD 4 count trended down to 382 Atripla therapy was initiated. He reported no reoccurrence of symptoms on his last visit in August 2011 and is at present tolerating his HAART medications with no side effects.