3 Methods:
His vital signs were stable (His blood pressure was 107/66 mm Hg, his
pulse was 88 beats/min, respiratory rate was 15 breaths/min and his
weight was 43 kg), and physical examination revealed normal respiratory
sounds with no added sounds. However, chest X-ray showed bilateral
diffuse interstitial prominence with nodular infiltrates.
The patient was initially started on empirical antituberculosis therapy
due to the high burden of tuberculosis in Sudan. However, after one
month, there was no improvement in symptoms. The patient returned to the
clinic with worsening fever, which was almost persistent during the
night. CT scan findings showed a patchy area of ground glass with
relative sparing of the apices and intralobular septal thickening, along
with nodular infiltrates in both lung fields (figure 1).
As the patient agreed to undergo bronchoscopy, normal airways with
normal mucosa were observed. Bronchial washings were collected from the
lower lobes bilaterally for microbiology, culture, and cytology testing.
Blood cultures showed no growth of any organism. Acid-fast bacilli smear
and culture, Nocardia and fungal smears and cultures, and GeneXpert
testing for tuberculosis were all negative. Cytological examination
ruled out malignancy and showed a three-dimensional alveolar cast
exhibiting the characteristic honeycomb appearance; immediately a
special stain was requested and the smear stained with methenamine
silver and after visualization under the microscope, a spherical cysts
(cup shaped, crinkled and crescent) were noticed approximately in the
size of the diameter of red blood cells (Figure 2). The patient’s blood
was tested for HIV, which came back reactive.