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A 28-year-old patient presents with fever, cough, night
sweats, and weight loss that have been present for 2 months.
He is currently unemployed and lives in a homeless shelter. He
is known to be HIV-positive but has not been receiving medical
care. On examination, he is febrile with a temperature of
38.8Â°C and crackles are heard in the lower lung fields on both
sides on lung auscultation. He has no enlarged peripheral lymph
nodes, and results of the rest of the examination are normal.
Laboratory results are as follows: hemoglobin 10.5 g/dL, leukocyte
count 11,500/Î¼L, platelet count 125,000/Î¼L, serum creatinine
1.3 mg/dL, CD4 cell count 105/Î¼L, HIV-1 RNA
150,000 copies/mL, and infiltrates in lower lobes bilaterally on
chest radiography. All the following statements can be made
about this patient except:
a. Evaluation should include examination and culture of the
sputum for bacteria.
b. Evaluation should include stains and culture of the sputum
for Mycobacterium tuberculosis.
c. The patient will require antiretroviral therapy.
d. Infiltrates in lower lobes and absence of cavitations exclude
tuberculosis as a diagnosis.
e. The patient will require prophylaxis against PCP.
When tuberculosis occurs later in the course of HIV infection, it
tends to have atypical features, such as extrapulmonary disease, disseminated
disease, and unusual chest radiographic appearance (lower
lung zone lesions, intrathoracic adenopathy, diffuse infiltrations,
and lower frequency of cavitation).
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