Episode Details

Dr. Kushal Vaishnani presents a clinical unknown on Virtual Morning Report to student Dr. Jean-Claude Guidi and Dr. Ramya Ramachandran.

Case Overview & Teaching Points

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Problem Representation
A 53-year-old woman with a history of rheumatoid arthritis and amiodarone-induced lung injury on immunosuppression presented with acutely progressive hypoxic respiratory failure and hypotension, found to have a serpiginous truncal rash, acute anemia, and elevated beta-d-glucan.

Schemas
In this episode, we revisit the schemas for fever and rash (which highlights first addressing the life-threatening causes) and diffuse alveolar hemorrhage (which focuses on differentiating vasculitis from other etiologies).

Diagnosis
The patient underwent bronchoscopy with bronchoalveolar lavage fluid demonstrating elevated leukocytes with a neutrophilic predominance as well as progressively bloody fluid, consistent with diffuse alveolar hemorrhage. Silver stain was diagnostic for Pneumocystis jiroveci, and pathology revealed helminthic larvae consistent with Strongyloides stercoralis. The patient was diagnosed with both Pneumocystis pneumonia and Strongyloides hyperinfection syndrome!

Teaching Points:

• Beta-D-glucan(BDG) is a cell wall polysaccharide found in many fungal organisms (with notable exceptions including Cryptococcus, the zygomycetes, and Blastomyces dermatitidis) and is frequently used as a laboratory marker for invasive fungal infections. Cauti