A 41-year-old man presented to the HIV clinic for a follow-up after a recent visit to the Emergency Department at another hospital for dysphagia. His medical history was significant for HIV infection with last known CD4+ count 1,271 cells/muL and undetectable viral load within the previous month. The patient was on HAART with EVG/c/FTC/TAF with adequate adherence for the past two years. He stated that his dysphagia progressed over 2 weeks, and it was initially associated with hiccups and then odynophagia and white pharyngeal plaques. In the Emergency Department, his laboratory exams showed a white blood cell count of 18 x 103/muL with monocyte predominance, and a chest X-ray revealed a new 2 cm right upper lobe infiltrate with nodular characteristics (Figure 1). The patient had normal vital signs and lacked respiratory symptoms. He was diagnosed with esophageal candidiasis, prescribed oral fluconazole, and was discharged home with pending outpatient follow-up of the abovementioned radiological findings. Of note, the patient did not disclose his HIV status during the encounter.
The next day, upon evaluation at the clinic, the patient denied cough, night sweats, fever or chills, but reported noticing a 5-pound unintentional weight loss, which he attributed to decreased appetite and swallowing difficulties. In addition, he reported using a self-initiated over-the-counter fluticasone nasal spray 2-3 times per day for at least 2 weeks prior to presentation. Other past medical history included essential hypertension and dyslipidemia. The patient had a documented history of positive tuberculin skin test and had completed 6 months of treatment with isoniazid 21 years prior to this presentation. He had a negative chest X-ray within the past year. He had a family history of type-2 diabetes. Social history was significant for trips to visit his family in Philippines and Mexico during the previous year and daily tobacco smoking for 17 years. On exam, he was not in respiratory distress and had mild posterior pharyngeal and nasal erythema. The rest of the physical examination was noncontributory. Given the abnormal X-ray findings and the suspicion for immunosuppression based on the presence of esophageal candidiasis, the patient was immediately placed on airborne precautions and a chest computed tomography (CT) scan was ordered, which revealed a new thick-walled right upper lobe cavitary nodule measuring 19 x 14 mm (Figure 2). The patient was admitted to the inpatient ward for further evaluation. Bronchoalveolar lavage (BAL), acid-fast bacillary (AFB) smear, and cultures were all negative. Serology for Aspergillus, Blastomyces, Histoplasma, and Cryptococcus were negative. Polymerase chain reaction in serum for cytomegalovirus was negative. A CT-guided lung biopsy of the nodular lesion was performed, and the AFB culture yielded Mycobacterium tuberculosis. Therefore, the decision was made to start antituberculosis therapy with rifabutin, isoniazid, pyrazinamide, and ethambutol, and the HAART regimen was switched to efavirenz/emtricitabine/tenofovir disoproxil fumarate for a better drug interaction profile. Rifabutin was prescribed at an oral daily dose of 450 mg due to interaction with efavirenz. The patient was discharged in stable condition and currently has regular follow-ups in our HIV clinic.