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.