Man with dyspnea

Abstract

A 55‐year‐old man with a history of HIV presented to the emergency department (ED) with a 2‐week history of cough and dyspnea. He also reports subjective fevers and states he has been off his antiretroviral medications for the past 8 months. Vital signs were notable for a low‐grade fever and a room air pulse oximetry of 82%. Point‐of‐care ultrasound (POCUS) of the thorax and portable chest radiography (CXR) were performed (Figures 1 and 2). FIGURE 1 (A) Thoracic ultrasound image from the patient's anterior mid‐lung fields showing numerous B lines (located between the green lines, red lines, and yellow lines) seen in alveolar‐interstitial syndromes. Pleura is noted by the blue arrow. (B) Thoracic ultrasound image from the left inferior lung fields showing a subpleural consolidation (red arrow) often seen in pneumonia or pulmonary embolism/infarction FIGURE 2 Chest radiograph of the patient showing bilateral central and basilar pneumonia (infiltrates noted by the red arrows) greater on the right than the left 1 DIAGNOSIS Pneumocystis carinii pneumonia (PCP). POCUS of the lungs revealed B‐lines bilaterally in a diffuse, non‐dependent fashion, no pleural effusions, and a subpleural consolidation. CXR revealed bilateral pneumonia. Given that this patient presented to our ED during the peak of the coronavirus disease 2019 (COVID‐19) pandemic locally, it was presumed that he was suffering from this disease. He was admitted to the hospital, eventually intubated for progressive hypoxic respiratory failure, and successfully extubated on hospital day 3. Lab testing revealed negative COVID‐19 polymerase chain reaction and a Beta‐D‐Glucan level > 500 pg/mL making the diagnosis all but certain in this patient. Bronchoscopy was deferred because of the attendant risks of performing this invasive procedure during a pandemic. This case illustrates that the POCUS and CXR findings of COVID‐19 and PCP 1 may be difficult to distinguish. The natural history of the respective diseases are also similar with progressive hypoxia predominating. Other conditions that can cause POCUS findings similar to COVID‐19 (including PCP, pulmonary fibrosis, and pulmonary sarcoidosis) should be kept in mind when evaluating patients with POCUS during this pandemic. 2