2. lower lung
Bronchoscopy, p. 526 No tumor seen
Lung biopsy, p. 688 Pneumocystis jiroveci pneumonia (PCP)
Stool culture, p. 797 Cryptosporidium muris
Acquired immunodeficiency syndrome
(AIDS) serology, p. 265
p24 antigen Positive
Enzyme-linked immunosorbent assay
(ELISA)
Positive
Western blot Positive
Lymphocyte immunophenotyping, p. 274
Total CD4 280 (normal: 600–1500 cells/L)
CD4% 18% (normal: 60%–75%)
CD4/CD8 ratio 0.58 (normal: >1.0)
Human immune deficiency virus (HIV)
viral load, p. 265
75,000 copies/mL
3. Diagnostic Analysis
The detection of Pneumocystis jiroveci pneumonia (PCP)
supports the diagnosis of AIDS. PCP is
an opportunistic infection occurring only in
immunocompromised patients and is the most
common infection in persons with AIDS. The patient’s diarrhea
was caused by Cryptosporidium
muris, an enteric pathogen, which occurs frequently with AIDS
and can be identified on a stool
culture. The AIDS serology tests made the diagnoses. His viral
load is significant, and his
prognosis is poor.
The patient was hospitalized for a short time for treatment of
PCP. Several months after he was
discharged, he developed Kaposi sarcoma. He developed
psychoneurologic problems eventually
and died 18 months after the AIDS diagnosis.
6. Studies Result
Electrocardiogram (EKG), p. 485 Ischemia noted in anterior
leads
Chest x-ray study, p. 956 No active disease
Complete blood count (CBC), p.
156
Red blood cell (RBC) count, p.
396
2.1 million/mm (normal: 4.7–6.1 million/mm)
RBC indices, p. 399
Mean corpuscular volume
(MCV)
72 mm
3
(normal: 80–95 mm
3
)
Mean corpuscular hemoglobin
(MCH)
22 pg (normal: 27–31 pg)
7. Mean corpuscular hemoglobin
concentration (MCHC)
21 pg (normal: 27–31 pg)
Red blood cell distribution width
(RDW)
9% (normal: 11%–14.5%)
Hemoglobin (Hgb), p. 251 5.4 g/dL (normal: 14–18 g/dL)
Hematocrit (Hct), p. 248 18% (normal: 42%–52%)
White blood cell (WBC) count, p.
466
7800/mm
3
(normal: 4,500–10,000/mcL)
WBC differential count, p. 466 Normal differential
Platelet count (thrombocyte
count), p. 362
Within normal limits (WNL) (normal: 150,000–
400,000/mm
3
)
9. Vitamin B12, p. 460 140 pg/mL (normal: 100–700 pg/mL)
Folic acid, p. 218 12 mg/mL (normal: 5–20 mg/mL or 14–34
mmol/L)
Diagnostic Analysis
The patient was found to be significantly anemic. His angina
was related to his anemia. His
normal RBC survival studies and normal haptoglobin eliminated
the possibility of hemolysis..
His RBCs were small and hypochromic. His iron studies were
compatible with iron deficiency.
His marrow was inadequate for the degree of anemia because
his iron level was reduced.
On transfusion of O-positive blood, his angina disappeared.
While receiving his third unit of
packed RBCs, he developed an elevated temperature to 38.5°C,
muscle aches, and back pain.
The transfusion was stopped, and the following studies were
performed:
Studies Results
Hgb, p. 251 7.6 g/dL
10. Hct, p. 248 24%
Direct Coombs test, p. 157 Positive; agglutination (normal:
negative)
Platelet count, p. 362 85,000/mm
3
Platelet antibody, p. 360 Positive (normal: negative)
Haptoglobin, p. 245 78 mg/dL
Diagnostic Analysis
The patient was experiencing a blood transfusion
incompatibility reaction. His direct Coombs
test and haptoglobin studies indicated some hemolysis because
of the reaction. His platelet count
dropped because of antiplatelet antibodies, probably the same
ABO antibodies that caused the
RBC reaction.
He was given iron orally over the next 3 weeks, and his Hgb
level improved. A rectal
examination indicated that his stool was positive for occult
blood. Colonoscopy indicated a right-
11. side colon cancer, which was removed 4 weeks after his initial
presentation. He tolerated the
surgery well.
Critical Thinking Questions
1. What was the cause of this patient's iron-deficiency anemia?
2. Explain the relationship between anemia and angina.
3. Would your recommend B12 and Folic Acid to this patient?
Explain your rationale for
the answer
4. What other questions would you ask to this patient and what
would be your rationale for
them?