A 26-Year-Old Man with Productive Cough, Hemoptysis, and Weight Loss

WHAT IS YOUR DIAGNOSIS?An Iranian 26-year-old man was referred to our hospital with chief complaints of productive cough and hemoptysis. He presented with fever, cough, weight loss of 4 kg within the past month, and no history of other diseases. He also had a history of unprotected sexual contact and inhalational heroin abuse. On physical examination on the day of admission to our hospital, the patient was febrile (38.5 °C) with a pulse rate of 116 beats/min. Physical examination was unremarkable except for oropharyngeal candidiasis. The chest radiography (CXR) revealed a cavitary lesion in the left upper lobe (LUL) and parenchymal infiltration in the right upper lobe (RUL) (Figure 1A). The complete blood cell count results were normal except for a Hemoglobin count of 10.7 g/dl and a platelet count of 105,000/ml. The erythrocyte sedimentation rate was 97 mm/h. Alanine transaminase and Aspartate aminotransferase raised slightly to 54 mg/dl and 50 mg/dl (upper limit of normal: 40), respectively. The electrolyte profile, renal function test results, and urinalysis were normal. Therefore, we performed a lung computed tomography (CT) scan (Figure 1B). Sputum smears for acid-fast bacilli were negative three times. Empirical antibiotic therapy with Imipenem and Azithromycin was started. In complementary laboratory studies, test results were positive for Human Immunodeficiency virus (HIV) and Hepatitis C virus (enzyme-linked immunoassay and Polymerase Chain Reaction). Flow cytometry analysis of peripheral blood mononuclear cells demonstrated a CD4+ lymphocyte count of 13. No improvement in symptoms was obtained after empirical treatment. So, we repeated CXR and, after that, a lung CT scan which showed that pulmonary infiltration on the right side had worsened (Figure 1C and 1D), so bronchoscopy and bronchoalveolar lavage (BAL) were performed. BAL smear was negative for acid-fast bacilli, and pneumocystis jiroveci was not observed in special staining.  On the 10th day of admission, a non-tender, mildly erythematous mass lesion on the left forearm was found during the daily visit (Figure 2). Ultrasonography of the lesion showed an abscess without any sign of bone invasion. This cold abscess's pus culture yielded non-acid fast, gram-positive filamentous bacilli.