A 20-year-old Hispanic male with no past medical history presented to our institution complaining of generalized weakness for 4 weeks, progressive cough with yellowish sputum, as well as persistent shortness of breath for 3 weeks, and intermittent fever and chills for 3-5 days prior to admission. Family history was remarkable only for coronary artery disease in his father. He denied smoking, alcohol, and using illegal drugs. He had lived with his girlfriend for 2 years and stated to be monogamous over this period. He reported a total of two sexual partners in his life. He was born in Texas and had not traveled outside the US for the last 12 years. Physical examination revealed a cachectic and tachypneic patient in no acute distress with bilateral diffuse crackles and rhonchi. The initial laboratory workup was within normal limits. Computed tomography of the chest (Figure 1) showed diffuse tree-in-bud nodularity, bronchiectasis, and thick-walled cavities in the upper lobes and moderate right simple pleural effusion. The HIV-rapid enzyme-linked immunosorbent assay test was reactive. The acid-fast bacilli sputum test was positive, and the patient was started on combination treatment for tuberculosis. The patient improved clinically over the next 3 days. The HIV Western blot test was negative; the viral load was undetectable. The CD4+ and CD8 counts were low (124 and 185, respectively) with a low CD4:CD8 ratio of 0.7. Further workup including immunoglobulin A, immunoglobulin G, and immunoglobulin M levels, urine protein electrophoresis, and serum protein electrophoresis was unremarkable. The pleural fluid cytology revealed atypical lymphocytes consistent with the established diagnosis of pulmonary tuberculosis. Further imaging of the abdomen and pelvis showed no abnormalities.
In addition, 8 weeks after discharge the patient was seen in clinic. He was taking his medication to treat tuberculosis and had regular health care follow-up. He was found to be completely asymptomatic with a CD4+ count of 188 cells/mm3. The repeated HIV test was negative, and the viral load was undetectable. After finishing his treatment for tuberculosis, he was evaluated in clinic, had a CD4+ count of 212 cells/mm3, and remained asymptomatic.
CT of the chest (in lung window) showing multiple thick-walled cavities in both upper lobes with diffuse tree-in-bud nodularities. . Abbreviation: CT, computed tomography.