A 39-year-old citizen from Martinique of African descent (overseas French territory, West French Indies), having lived in metropolitan France since July 2002, was admitted to Amiens University Hospital Center, Amiens, France, on 11 November 2003. The patient presented with fever, dyspnea, asthenia, and an alveolo-interstitial pulmonary syndrome. The patient had been infected with human immunodeficiency virus (HIV) since 1987 and had refused to be treated with highly active antiretroviral therapy (HAART) and to follow prophylaxis for opportunistic infections. A bronchoalveolar lavage (BAL) was performed, and specimens were sent to the laboratory of parasitology and mycology for microscopic examination and fungal culture. Initial examination of BAL specimens by use of an immunofluorescence assay (Bio-Rad, Marnes-La-Coquette, France), Uvitex-2 B, and Wright-Giemsa staining resulted in diagnosis of Pneumocystis pneumonia (PCP). The CD4+ T-cell count and the viral load in the blood were 38 cells/μl and >75,000 RNA copies/ml, respectively. Clinical improvement was obtained using cotrimoxazole treatment for 10 days, which was switched to atovaquone treatment at 1,500 mg per day because of an allergic reaction to sulfonamide. Fungal cultures of the BAL specimen at 35°C as well as 25°C were still negative 4 weeks after BAL specimen retrieval. The patient was discharged on 29 November. On 1 January 2004, the patient was readmitted to the hospital because of fever, diarrhea, severe asthenia, oral ulcers, and numerous skin lesions. Blood cultures for bacteria and fungi were negative. Microscopic examination of skin biopsy specimens revealed numerous small yeasts. These findings are the reasons for reexamination of the Wright-Giemsa stain of the specimen from the BAL performed in November 2003. The reexamination demonstrated a macrophage containing intracytoplasmic elements that are depicted in Fig. 1.
Fig 1.
Wright-Giemsa stain of a bronchoalveolar lavage specimen (magnification, ×650).
(For answer and discussion, see page 3165 in this issue [doi:10.1128/JCM.01477-12].)