Posted: February 5th, 2023

A 39-year-old homeless man presents to the emergency

A 39-year-old homeless man presents to the emergency department for cough and fever. He says that his illness has been worsening over the past 2 weeks. He originally had dyspnea on exertion and now is short of breath at rest. On questioning, he tells you that he lives in a homeless shelter when he can, but he frequently sleeps on the streets. He has used IV drugs (primarily heroin) “on and off” for many years. He denies medical history but the only time he gets medical attention is when he comes to the emergency department for an illness or injury. On review of systems, he complains of fatigue, weight loss, and diarrhea. On examination, he is a thin, disheveled man appearing much older than his stated age. His temperature is 100.5°F (38.0°C), his blood pressure is 100/50 mm Hg, his pulse is 105 beats/min, and his respiratory rate is 24 breaths/min. His initial oxygen saturation is 89% on room air, which comes up to 94% on 4 L of oxygen by nasal cannula. Significant findings on examination include dry mucous membranes, a tachycardic but regular cardiac rhythm, a benign abdomen, and generally wastedappearing extremities. His pulmonary examination is significant for tachypnea and fine crackles bilaterally, but no visible signs of cyanosis. His chest x-ray is read by the radiologist as having diffuse, bilateral,
interstitial infiltrates that look like “ground glass.”
Answer the following questions
What is the most likely cause of this patient’s current pulmonary
complaints?
➤ What underlying illness does this patient most likely have?
➤ What testing and treatment should be started now?

The most likely cause of the patient’s current pulmonary complaints is pneumonia, which can be seen from the findings of diffuse, bilateral interstitial infiltrates on chest x-ray that look like “ground glass.” The use of IV drugs, the history of homelessness and sleeping on the street, and the symptoms of fatigue, weight loss, and diarrhea are additional risk factors for pneumonia.

The underlying illness that this patient most likely has is acquired immunodeficiency syndrome (AIDS). The history of IV drug use, which puts the patient at risk for bloodborne viruses, combined with the symptoms of fatigue, weight loss, and diarrhea, are consistent with AIDS.

Immediate testing and treatment should be started to address the patient’s condition. This includes obtaining blood cultures and starting antibiotics to treat the pneumonia, as well as ordering tests to determine the patient’s HIV status and to assess the severity of the patient’s immunodeficiency. The patient’s oxygen saturation should also be monitored and supplemental oxygen provided as needed. If the patient is found to have HIV, antiretroviral therapy should be initiated as soon as possible to manage the virus and prevent progression to AIDS. In addition, the patient should be referred to a shelter or other resources to address the issue of homelessness and to help ensure proper follow-up and care.

References:
Centers for Disease Control and Prevention. (2021). Pneumonia. Retrieved from https://www.cdc.gov/pneumonia/index.html
World Health Organization. (2021). Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS). Retrieved from https://www.who.int/health-topics/human-immunodeficiency-virus-hiv-/#tab=tab_1
National Institute of Allergy and Infectious Diseases. (2021). HIV and AIDS. Retrieved from https://www.niaid.nih.gov/diseases-conditions/hiv-aids

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