Premature bullous pulmonary damage in AIDS.

Case report (Dr R F Miller) A 31 year old Caucasian man was admitted to this hospital for investigation offever, progressive weight loss and cavitating lesions on his chest radiograph. The patient was a business man, he was homosexual and denied intravenous drug abuse. He smoked 30 cigarettes per day and drank 2 units of alcohol per week. His past medical history began in 1977 when he suffered from rectal gonococcus. In 1984 he developed oral candidiasis. Later on in 1986 he requested an HIV test. Following counselling he was found to be HIV-1 antibody positive. At this time he had further oral candidiasis and developed persistent generalised lymphadenopathy. In April 1988 Giardia lambia was isolated in his stool. Because of persistent oral candidiasis he was commenced on ketoconazole, and zidovudine was also begun. In July of that year he presented with a 3-week history of fever, exertional dyspnoea and a non-productive cough. His chest radiograph was typical for Pneumocystis carinii pneumonia so bronchoscopy was not performed and the patient was treated with oral high-dose cotrimoxazole. He made a rapid recovery, complicated by the development ofa severe skin rash after 10 days therapy. He completed treatment with nebulised pentamidine. Following discharge from hospital he recommenced zidovudine and received intermittent nebulised pentamidine prophylaxis. He re-presented in September 1988 with further fever and cough associated with pleuritic pain, together with generalised myalgia. A sample of sputum, expectorated spontaneously, was negative for bacteria and acidand alcohol-fast bacilli (AAFB). Culture of the sputum was also negative. His chest radiograph at that time (fig 1) showed an area of consolidation in the right upper zone. Within this area were several cavities. Despite the atypical presentation he was treated empirically for presumptive Pneumocystis carinii pneumonia with nebulised pentamidine. After 2 weeks treatment there had been no response, so the patient proceeded to fibre-optic bronchoscopy. At bronchoscopy the endobronchial appearances were normal. Transbronchial biopsy