A 62-year-old male with no known medical history was brought to our hospital after having been found by his coworkers on the floor at work earlier that morning. The patient had no recollection of falling, was confused, and was unable to recognize his coworkers. He only complained of new right shoulder pain. The patient worked in a telemarketing office. He became homeless 1 year previously, sleeping at work intermittently or staying with friends. The patient occasionally used marijuana, and did not smoke cigarettes, use injected drugs or drink alcohol. The patient was bisexual with his last sexual encounter 2 years previously.
The patient presented with subjective fevers, loss of appetite with significant weight loss, and fatigue for the previous few months. He noted a flaky full, body rash, episodic dizziness, confusion, worsening vision and frequent falls. He also had non-productive cough, episodic diarrhea and urinary incontinence for several months.
In the Emergency Department, the temperature was 101.9  F, and heart rate was 106 beats per minute. Physical examination revealed a cachectic man with depressed affect. The patient had areas of dry scaly skin on the head, trunk, and extremities. There were multiple violaceous papules of the extremities and trunk (Fig. 1). Oral examination revealed poor dentition and oral thrush. There were rales on auscultation of the right lung. Cardiovascular and abdominal examinations were unremarkable. There was mild edema of the bilateral lower extremities and pain and limitation to range of motion of the right shoulder.
The leukocyte count was 2600 u L, hemoglobin 10.6 gm/dL, and international normalized ratio was 1.4. Venous blood gas showed pH 7.464 and lactic acid 1.9 mmol/L. Creatine kinase -MB was 2726 IU/L. Liver function tests showed an albumin of 2.7 g/dL, direct bilirubin of 0.5 mg/dL, aspartate aminotransferase of 88 IU/L and alkaline phosphatase of 883 IU/L. HIV-1/2 EIA was reactive. Radiograph of the right shoulder showed a non-displaced midshaft fracture of the right clavicle. Chest radiograph (CXR) revealed a right middle lobe pneumonia. Computed tomography (CT) of the head showed no mass, acute hemorrhage or acute infarct. Treatment with ceftriaxone and azithromycin was begun.
An ophthalmology examination was negative for retinitis but revealed bilateral cataracts. A punch biopsy was performed of the skin lesions, which confirmed Kaposi sarcoma. A peripheral smear showed dysplastic neutrophils and toxic granulation. The red blood cells had poikilocytosis and there were rare schistocytes seen. The platelet count was adequate. CT scan of the chest/abdomen/pelvis with IV contrast showed moderate consolidation in right middle and upper lobes. There were faint ground glass densities in the left upper lobe as well as mild emphysematous changes throughout (Fig. 2). The scan also showed a moderate-sized multi-loculated right distal perirectal and proximal right perianal abscess with rim enhancement. The abscess was drained, and cultures grew Pseudomonas aeruginosa and Escherichia coli.
Bronchoscopy performed on hospital day 5 showed oropharyngeal candidiasis and thick viscous secretions in right middle and lower lobe. IV fluconazole was started. The bronchial washings were negative for malignant cells or acid-fast bacilli (AFB). Respiratory culture and smear grew Pseudomonas aeruginosa. Urine chlamydia and gonorrhea were both not detected, cytomegalovirus (CMV) IgM antibody was negative and QuantiFeron TB Gold (QIAGEN, Hilden, Germany) was also negative. The HIV viral load was 551,166 copies/mL, the absolute CD4 count was 6 cells/ mcL and the CD4 percentage was 2%. Syphilis antibody was positive. Reflex rapid plasma reagin (RPR) was reactive, and the titer was 1:32. Lumbar puncture (LP) was performed on hospital day 8 and cerebrospinal fluid (CSF) venereal disease research laboratory (VDRL) was positive. The cell count was normal, protein was 72 mg/dL, glucose was 50 mg/dL and Cryptococcal antigen was negative. Intravenous penicillin G was started, as was antiretroviral therapy (ART) with tenofovir/emtricitabine and dolutegravir. On hospital day 9, bone marrow biopsy was performed. Core biopsy sections were normocellular with normal appearing hematopoiesis. AFB and Gomori-Grocott methenamine silver stains showed no organisms. Immunohistochemical stains showed almost exclusively T-cells (CD3+) and rare B-cells (CD20+).
The patient was discharged on hospital day 32 on the following oral medications; trimethoprim/sulfamethoxazole for PJP primary prophylaxis and antiretroviral therapy.