A 5-year-old HIV-infected boy with rash and abdominal pain (page 2/3)
Prepared by...
Virat Sirisanthana, M.D. *
* Department of Pediatrics, Chiang Mai University
The differential diagnosis includes:
Varicella pneumonia
Bacterial pneumonia
Pneumocystis jirovecii (Pneumocystis carineii) pneumonia
Unmasking of previously undiagnosed mycobacterial infection

Varicella pneumonia is the most likely diagnosis
Reasons include:

Symptom of pneumonia occurred on day 2-3 of the varicella rash.

> Respiratory symptom was not severe on admission
> CXR: perihilar interstitial infiltration
Bacterial pneumonia is the second
Reasons include:
> He is the immunocompromised (HIV-infected) host.
> CXR: perihilar interstitial infiltration and early alveolar infiltration was seen at rt. middle lung field
> Bacteria especially Staphylococcus aureus tends to superinpose on varicella pneumonia

Pneumocystis jirovecii (Pneumocystis carineii) pneumonia:
"PRO"reasons include:
> He was not on PCP primary prophylaxis.
> It is the most common cause of pneumonia in AIDS patients (his CD4 T cell count was 4%).
"CON"reasons include:
> He was not as hypoxemia as a case of PCP
Unmasking of previously undiagnosed pumnonary tuberculosis due to "Immune reconstitution syndrome"
"PRO"reasons include: (ref 1,2)
> History of pulmonary disease in his father.
> His CD4 T cell was very low (4%) at the time of ART initiation.
> The illness occurred within the first 8 weeks after ART initiation.
"CON"reasons include:
> At the time of this illness (admission) he still have lymphopenia. It is likely that his CD4 T-cell count is still very low.
> CXR of "previously undiagnosed pulmonary tuberculosis" is more likely to demonstrate "enlarged hilar nodes"

Progression: Next

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