Diagnostic Dilemma

HIV and bronchiectasis

A 7 years old HIV infected girl presented with cough for 2 months and fever for 2 months. Both parents were on antiretroviral therapy {ART} and father had tuberculosis {TB} 3 years ago and mother had TB 6 years ago. On examination, weight was 15 kg, height was 104 cms. She had clubbing with generalized non-significant lymphadenopathy and bilateral leathery crepts in the posterior scapular region. Chest X-Ray showed right lower zone consolidation. Mantoux test was negative. CT Chest showed several large patchy consolidations in bilateral lung with multiple enlarged mediastinal nodes. She was thus started on antituberculous therapy {ATT} consisting of Isoniazid {H}, Rifampicin {R}, Pyrazinamide {Z} and Ethambutol {E}. Her CD4 count was 321, cumm. However, she continued to have cough and there was no weight gain with chest X-Ray showing bronchiectatic changes after 2 months of therapy. She was then started on ART consisting of Zidovudine {AZT, Lamivudine {3TC} and Efavirenz {EFV}, However she had no response and after 4 months of ART, she underwent bronchoscopy and bronchoalveolar lavage {BAL} was sent for TB culture.

What is the cause of her bronchiectasis__? How to manage this child__?
Expert Opinion :
Wonderful answers. Most of you have replied about PCP. However this child has symptoms since 2 months {PCP should have caused severe hypoxia by now}, CT shows mediastinal nodes {unlikely with TB} and bronchiectasis with clubbing which remains unexplained by PCP.

Regarding TB, yes it is a possibility in view of mediastinal nodes, consolidation and both parents having suffered TB. But this child is already on anti TB treatment since past 4 months and has not shown any improvement. Thus it may either be drug resistant TB for which BAL has been done.

However suppose the BAL does not grow TB on culture, what else is possible_?
Answer Discussion :
Rolando Lezama
pneumocystis carini ifection
12 years ago
Kim Seng Lee
Cystic Fibrosis with PTB
12 years ago

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