28 years old malay male patient from Pokok Mangga, Melaka who is a ex-factory worker was admitted 4 days ago with the chief complaints of fever for 5 days , cough and purulent sputum for 3 days and right chest pain for 2 days.

The patient is a known AIDS patient since 1 year ago. The fever is moderate, intermittent and associated with chills and rigors. The cough for 3 days and associated with purulent sputum and foul smelling, no hemotypsis. The patient also complained of right pleuritic chest pain which is sudden in onset, severe, continuous, pricking type of pain, aggravated by breathing and slightly relieved by pain killer. No histoty of breathlessness, nausea and vomitting, abdominal pain, headache, seizures.

The patient is known to have HIV positive since 1 year ago. There is history of IVDU and sexual promiscuity. There are also history of syphilis, hepatitis B and C, and septic arthritis. Surgery was done 4 months ago to drain the pus in the right knee joint (septic arthritis).

On examination, the patient is sick, moderately built but poorly nourished. The skin of the whole body appears to be scally and rashous. There is pallor, and jaundice, and aphthous ulcer and gingivitis in the oral cavity, IVDU mark on the right arm. Vital signs are stable. On respiratory examination, trachea central and there is reduce chest movement on the right side and impaired dullness, broncial breath sound and crepitations over the right infraclavicular and mammary areas. Other systemic examinations unremarkable.

Chest X-ray shows right middle and lower zone consodilation. Blood culture shows streptococcal pneumoniae. CD4 count 326 cells/ul, VDRL , Hepatitis B and C positive.

Diagnosis: Pneumococcal pneumonia with syphilis, hepatitis B and C and gingivitis and oral aphthous ulcer with underlying AIDS.

Discussion:
Commonest causes of HIV-related acute respiratory distress are bacterial pneumonia. The features of bacterial pnuemonia are acute symptoms (3-5 days), fever with chills and rigors, pleuritic chest pain, productive cough with purulent sputum, focal signs in the lungs and CD4 count <500 cells/ul. The patient may also present with other clinical manifestations of immunocompromised status at the same time.