Medical Specialties Commons^™

The Frequency Of Heparin Induced Thrombocytopenia In Patients Undergoing Elective Cardiac Bypass Surgeries, Natasha Bahadur Ali, Bushra Moiz, Yasmin Rehman, Mohammad Salman, Shahid Ahmed Sami

Department of Pathology and Laboratory Medicine

Objective: To determine the frequency of Heparin Induced Thrombocytopenia (HIT) in patients undergoing elective cardiac bypass surgeries and to observe the platelets evolution post surgically in these patients.
Method: A prospective study was designed and 100 unselected consecutive patients undergoing elective cardiac bypass surgery were enrolled and evaluated. The clinical and laboratory details were noted before and after surgery. Their platelet counts were observed from day 0 (prior to surgery) to day 5 post operatively. Particle gel immunoassay was used to demonstrate the presence of antibodies against heparin-platelet factor 4 complexes.
Results: There were 86 males and 14 females with …

Diffusion Weighted Image (Dwi) Findings In Methanol Intoxication., Humera Ahsan,, Muhammad Akbar, Aamir Hameed

Department of Medicine

Methanol is a toxic substance with extremely devastating effects upon exposure. The case described suffered from such kind of poisoning. MRI brain demonstrated necrosis bilaterally in the Putamen areas which is a classic hallmark finding. Additional Diffusion weighted imaging showed abnormal signal bilaterally in the putamen areas along with Diffusion positive bilateral lesions (possibly infarctions) in both the frontal and occipital lobes that were not evident on MRI with or without contrast.

Use Of Triple-Site Ventricular Pacing In A Patient With Severe Congestive Heart Failure And Atrial Fibrillation., Faizel Osman, Jeilan Mohamed, G. Andre' Ng

Internal Medicine, East Africa

Cardiac resynchronization therapy (CRT) has become an accepted treatment for selected patients with drug-resistant heart failure. Data for patients in atrial fibrillation (AF) remains limited but suggests benefit in these patients too. We report the case of an 82-year-old patient with heart failure, VVIR permanent pacemaker, and permanent AF who had an upgrade to triple-site CRT implantation with good clinical response. Triple-site ventricular pacing may enhance the chance of response and LV reverse remodeling and should be considered in AF patients undergoing CRT implantation.

The Pakistan Risk Of Myocardial Infarction Study: A Resource For The Study Of Genetic, Lifestyle And Other Determinants Of Myocardial Infarction In South Asia, Danish Saleheen, Moazzam Zaidi, Asif Rasheed, Usman Ahmad, Abdul Hakeem, Muhammed Murtaza, Waleed Kayani, Rashid Jooma, Nadir Khan, Nabi Shah, Asad Ali Shah, Maria Samuel, Farina Hanif, Madiha Yameen, Sobia Naz, Aisha Sultana, Aisha Nazir, Shehzad Raza, Muhammad Shazad, Sana Nasim, Muhammad Ahsan Javed, Syed Saadat Ali, Mehmood Jafree, Muhammad Imran Nisar, Altaf Hussain, Ayeesha Kamran Kamal, Philippe M. Frossard

Department of Biological & Biomedical Sciences

The burden of coronary heart disease (CHD) is increasing at a greater rate in South Asia than in any other region globally, but there is little direct evidence about its determinants. The Pakistan Risk of Myocardial Infarction Study (PROMIS) is an epidemiological resource to enable reliable study of genetic, lifestyle and other determinants of CHD in South Asia. By March 2009, PROMIS had recruited over 5,000 cases of first-ever confirmed acute myocardial infarction (MI) and over 5,000 matched controls aged 30-80 years. For each participant, information has been recorded on demographic factors, lifestyle, medical and family history, anthropometry, and a …

An Adrenal Beta-Arrestin 1-Mediated Signaling Pathway Underlies Angiotensin Ii-Induced Aldosterone Production In Vitro And In Vivo., Anastasios Lymperopoulos, Giuseppe Rengo, Carmela Zincarelli, Jihee Kim, Stephen Soltys, Walter J Koch

Center for Translational Medicine Faculty Papers

Aldosterone produces a multitude of effects in vivo, including promotion of postmyocardial infarction adverse cardiac remodeling and heart failure progression. It is produced and secreted by the adrenocortical zona glomerulosa (AZG) cells after angiotensin II (AngII) activation of AngII type 1 receptors (AT(1)Rs). Until now, the general consensus for AngII signaling to aldosterone production has been that it proceeds via activation of G(q/11)-proteins, to which the AT(1)R normally couples. Here, we describe a novel signaling pathway underlying this AT(1)R-dependent aldosterone production mediated by beta-arrestin-1 (betaarr1), a universal heptahelical receptor adapter/scaffolding protein. This pathway results in sustained ERK activation and subsequent …

Primary Cardiac Tumors., Suraj Maraj, Md, Gregg S. Pressman, Md, Vincent M. Figueredo, Md

Division of Cardiology Faculty Papers

Primary cardiac tumors are a rare entity compared to tumors that metastasize to the heart. Patients with such tumors may be asymptomatic. Many cases are found incidentally during evaluation of an unrelated medical condition. It is important for the clinician to have a high index of suspicion when evaluating a patient presenting with signs and systemic symptoms concerning possible malignancy, plus cardiac specific symptoms or complications. These can include new onset dyspnea, congestive heart failure, arrhythmias or murmurs varying with body positions. Imaging, particularly the use of echocardiography, remains the cornerstone of diagnosis, and may be combined with new imaging …

Inflammatory Biomarkers And Subclinical Atherosclerosis In African-American Women With Systemic Lupus Erythematosus (Sle), Edith M. Williams, Carlos J. Crespo, Joan Dorn

Community Health Faculty Publications and Presentations

Women with lupus are at increased risk for developing cardiovascular disease (CVD). Previous studies of atherosclerosis in SLE have not been representative of the minority groups most affected by lupus and its complications. Therefore, a study of 41 lupus cases and 83 controls was conducted to investigate the relationship between carotid atherosclerosis and inflammation in African-American women. Participation consisted of a questionnaire, physical examination, fasting blood draw, and ultrasound of the carotid arteries. There were observed differences between cases and controls with regard to carotid intima media thickness (IMT) and traditional cardiovascular risk factors, although few reached statistical significance. Tumor …

Associated Symptoms In The Ten Days Before Diagnosis Of Kawasaki Disease., Annette L. Baker, Minmin Lu, L Luann Minich, Andrew M. Atz, Gloria L. Klein, Rosalind Korsin, Linda Lambert, Jennifer S. Li, Wilbert Mason, Elizabeth Radojewski, Victoria L. Vetter, Jane W. Newburger, Pediatric Heart Network Investigators, Girish S. Shirali

Manuscripts, Articles, Book Chapters and Other Papers

OBJECTIVE: To describe common associated symptoms within the 10 days before diagnosis in subjects enrolled in the Pediatric Heart Network's trial of steroid therapy in Kawasaki disease (KD).

STUDY DESIGN: Patients with acute KD were enrolled between days 4 and 10 of illness at 8 centers between 2002 and 2004. We defined common associated symptoms as those occurring in >or=10% of patients. Principal clinical criteria for KD were not included in this analysis.

RESULTS: Among 198 patients, irritability was reported in 98 (50%), vomiting in 88 (44%), decreased food/fluid intake in 73 (37%), cough in 55 (28%), diarrhea in 52 …

Universal Screening For Extracardiac Abnormalities In Neonates With Congenital Heart Disease., Javier H. Gonzalez, Girish S. Shirali, Andrew M. Atz, Sarah N. Taylor, Geoffrey A. Forbus, Sinai C. Zyblewski, Anthony M. Hlavacek

Manuscripts, Articles, Book Chapters and Other Papers

Extracardiac or genetic abnormalities (EGA) represent a factor in the morbidity of patients with congenital heart disease. We evaluated the way neonates with CHD are screened at our institution and determined the yield for the screening tests. We reviewed the charts of 223 neonates with structural CHD. Subjects were categorized into 6 groups: univentricular, left-sided obstructive lesions, right-sided obstructive lesions, septal defects, conotruncal defects (CTD), and other. We reviewed which patients underwent cranial ultrasonogram (CUS), abdominal ultrasonogram (AUS), and/or genetic studies (GS) as well as their results. There was a high prevalence of EGA in each group by CUS (32% …

Use Of Clopidogrel In The Reduction Of Myocardial Damage During Percutaneous Coronary Intervention, Arijit Dasgupta, Debabrata Mukherjee

Gill Heart & Vascular Institute Faculty Publications

It is estimated that approximately a quarter of patients undergoing coronary intervention may have significant post-procedural creatinine (CK)/creatinine kinase myocardial band (CK-MB) elevations and approximately half may have post-procedural troponin elevations. Current data suggest that periprocedural infarction is associated with short-, intermediate-, and long-term adverse outcomes, most notably mortality. This review examines the role of clopidogrel in decreasing periprocedural myonecrosis following percutaneous coronary intervention (PCI). Clopidogrel is an important pharmacologic agent used to reduce myocardial infarction post-coronary intervention as assessed directly by the evaluation of cardiac biomarkers and indirectly by the evaluation of short-term ischemic events. The optimal dose of …

Diurnal Variation Of The Human Adipose Transcriptome And The Link To Metabolic Disease., Andrey Loboda, Walter K. Kraft, Bernard Fine, Jeffrey Joseph, Michael Nebozhyn, Chunsheng Zhang, Yudong He, Xia Yang, Christopher Wright, Mark Morris, Ira Chalikonda, Mark Ferguson, Valur Emilsson, Amy Leonardson, John Lamb, Hongyue Dai, Eric Schadt, Howard E. Greenberg, Pek Yee Lum

Department of Anesthesiology Faculty Papers

ABSTRACT: BACKGROUND: Circadian (diurnal) rhythm is an integral part of the physiology of the body; specifically, sleep, feeding behavior and metabolism are tightly linked to the light-dark cycle dictated by earth's rotation. METHODS: The present study examines the effect of diurnal rhythm on gene expression in the subcutaneous adipose tissue of overweight to mildly obese, healthy individuals. In this well-controlled clinical study, adipose biopsies were taken in the morning, afternoon and evening from individuals in three study arms: treatment with the weight loss drug sibutramine/fasted, placebo/fed and placebo/fasted. RESULTS: The results indicated that diurnal rhythm was the most significant driver …

Alcohol In Moderation, Cardioprotection And Neuroprotection : Epidemiological Considerations And Mechanistic Studies, Dipak K. Das Dr.

UCHC Articles - Research

In contrast to many years of important research and clinical attention to the pathological effects of alcohol (ethanol) abuse, the past several decades have seen the publication of a number of peer-reviewed studies indicating beneficial effects of light-moderate, non-binge consumption of varied alcoholic beverages, as well as experimental demonstrations that moderate alcohol exposure can initiate typically cytoprotective mechanisms. A considerable body of epidemiology associates moderate alcohol consumption with significantly reduced risks of coronary heart disease and, albeit currently a less robust relationship, cerebrovascular (ischemic) stroke. Experimental studies with experimental rodent models and cultures (cardiac myocytes, endothelial cells) indicate that moderate …

Non-Invasive Prediction Of St Elevation Myocardial Infarction Complications By Left Ventricular Tei Index, Nasir Rahman, Khawar Abbas Kazmi, Muniza Yousaf

Section of Cardiology

OBJECTIVE: To investigate association between the Tei index and cardiac complications of ST elevation of Myocardial Infarction.

PATIENTS AND METHODS: A total of a 202 adult consecutive patients with first ST elevation MI (STEMI) were studied. Tei index was obtained as: (a _ b)/b, where "a" is the interval between the cessation and onset of mitral flow and "b" is the ejection time of aortic flow measured with the help of pulsed Doppler echocardiography. Subsequent complications, included Death, Congestive Heart Failure (CHF), Cardiogenic shock, Atrial Flutter/ Atrial Fibrillation, Sustained ventricular tachycardia, Advanced Atrio- Ventricular Clock (AV Block), Myocardial Infarction (MI), …

Secondary Prevention Of Heart Disease - Knowledge Among Cardiologists And Omega-3 (Omega-3) Fatty Acid Prescribing Behaviors In Karachi, Pakistan, Saqib A. Gowani, Sana Shoukat, Ather M. Taqui, Hashim M. Hanif, Wasiq F. Rawasia, Zeeshan Qadri, Sajid H. Dhakam

Section of Cardiology

Background: The use of omega-3 fatty acids is a currently proven strategy for secondary prevention of heart disease. The prescription practices for this important nutraceutical is not currently known. It is imperative to assess the knowledge of cardiologists regarding the benefits of omega-3 fatty acids and to determine the frequency of its prescription. The aim of the study was to determine the practices and associations of dietary fish prescribing among cardiologists of Karachi and to assess their knowledge of fish oil supplementation and attitudes toward dietary practices. Methods: A cross sectional survey was conducted during the period of January to …

Sildenafil For The Treatment Of Pulmonary Hypertension In Pediatric Patients, Alice J. Huddleston, Chad A. Knoderer, Jennifer L. Morris, Eric S. Ebenroth

Scholarship and Professional Work – COPHS

Sildenafil is a phosphodiesterase 5 inhibitor widely used for the treatment of pulmonary hypertension in children. Despite limited available safety and efficacy evidence, use of sildenafil continues to increase. To date, sildenafil use for pediatric pulmonary hypertension has been characterized for 193 children through 16 studies and 28 case series and reports. The primary efficacy data suggest that sildenafil is beneficial for facilitating the weaning of inhaled nitric oxide in children after cardiac surgery. Compiled safety data suggest that sildenafil is well tolerated among children with idiopathic pulmonary arterial hypertension and pulmonary arterial hypertension associated with congenital heart disease. This …

Dilemma In The Diagnosis Of Mediastinal Adenopathy In The South Asian Population-Role Of Ct Guided Biopsy, Mediastinoscopy And Video-Assisted Thoracoscopy (Vats), Marium Muzaffar, Hashim M Hanif, Saulat H. Fatimi

Section of Cardiothoracic Surgery

The diagnosis of mediastinal adenopathy is a dilemma amongst treating physicians especially in South Asia. This is because although tuberculosis is endemic in this region, many a times lymphoma and sarcoidosis cannot be excluded. Often patients are being treated with medications without a confirmed diagnosis. The Video-assisted thoracoscopy (VATS) has revolutionized the way mediastinal adenopathy is diagnosed and managed in this part of the world.

Pulmonary Vein Isolation Using A High Density Mesh Ablator Catheter: Incorporation Of Three-Dimensional Navigation And Mappin, Jiun Tuan, Jeilan Mohamed, Faizel Osman, Suman Kundu, Rajkumar Mantravadi, Peter J. Stafford, G. André Ng

Internal Medicine, East Africa

Background: We evaluated the use of a novel High Density Mesh Ablator (HDMA) catheter in combination with three-dimensional navigation for the treatment of paroxysmal atrial fibrillation.

Methods: The HDMA catheter was used to carry out pulmonary vein isolation in a consecutive series of patients. Three-dimensional geometry of the left atrial-pulmonary vein (LA-PV) junctions were first created with the HDMA catheter. Ostial, proximal and distal sites within the pulmonary veins were tagged with catheter shadows on the created geometry to allow for re-interrogation of these exact sites after ablation.

Results: The HDMA catheter was successfully used to create three dimensional geometry …

Outcome And Factors Associated With Hospital Mortality In Patients With Impaired Left Ventricular Function Undergoing Coronary Artery Bypass Grafting: Where Do We Stand?, Mubashir Zareen Khan, S Perveen, Ja Ansari, Sa Sami, S Furnaz, Saulat H. Fatimi

Section of Cardiothoracic Surgery

Objective: Impaired ventricular function is a known risk factor for mortality after coronary artery bypass grafting however increasingly more patients with impaired ventricular function are referred for surgery. Currently no large data is available from Pakistan regarding this aspect of coronary surgery. Our objectives were to find out the hospital mortality and mid term functional improvement in patients with impaired ventricular function undergoing coronary artery by pass grafting and identify the risk factors for mortality.
Methodology: Retrospective analysis of preoperative, operative and postoperative variables of patients with impaired ventricular function who were operated for isolated first time coronary artery …

Letter By Jeilan Et Al Regarding Article, "Longitudinal Strain Delay Index By Speckle Tracking Imaging: A New Marker Of Response To Cardiac Resynchronization Therapy"., Jeilan Mohamed, Jiun H. Tuan, G. Andre' Ng

Internal Medicine, East Africa

We read with interest the recent article by Lim et al.1 This article demonstrated a strong correlation between a novel longitudinal strain delay index and left ventricular end-systolic volume reduction in both ischemic and nonischemic patients.

The principle outlined by the authors is that an increased longitudinal strain delay index requires both dyssynchrony (defined in their article as a discrepancy between the time of end-systolic contraction and the time to peak strain) and residual contractility. Their concept elegantly considers the problem of cardiac resynchronization therapy (CRT) nonresponse in heart failure patients who have myocardial segments with delayed contraction due …

Maturation Of The Human Fetal Startle Response: Evidence For Sex-Specific Maturation Of The Human Fetus, Claudia Buss, Elyssia Poggi Davis, Quetzal A. Class, Matt Gierczak, Carol Pattillo, Laura M. Glynn, Curt A. Sandman

Psychology Faculty Articles and Research

Despite the evidence for early fetal experience exerting programming influences on later neurological development and health risk, very few prospective studies of human fetal behavior have been reported. In a prospective longitudinal study, fetal nervous system maturation was serially assessed by monitoring fetal heart rate (FHR) responses to vibroacoustic stimulation (VAS) in 191 maternal/fetal dyads. Responses were not detected at 26 weeks gestational age (GA). Sex-specific, age-characteristic changes in the FHR response to VAS were observed by 31 weeks' GA. Males showed larger responses and continued to exhibit maturational changes until 37 weeks'GA, females however, presented with a mature FHR …

Training New Mothers In Infant Cardiopulmonary Resuscitation (Cpr), Gavin C. Barr Jr. Md, Marna R. Greenberg Do, Mph, Facep, Valerie Rupp Rn, Bsn, Charles C. Worrilow Md, Katie Fredericks, Anne Marie Crown, John Reed Rrt

Department of Emergency Medicine

No abstract provided.

Rationale And Design Of A Trial Of Angiotensin-Converting Enzyme Inhibition In Infants With Single Ventricle., Daphne T. Hsu, Seema Mital, Chitra Ravishankar, Renee Margossian, Jennifer S. Li, Lynn A. Sleeper, Richard V. Williams, Jami C. Levine, Brian W. Mccrindle, Andrew M. Atz, Darlene Servedio, Lynn Mahony, Pediatric Heart Network Investigators, Girish S. Shirali

Manuscripts, Articles, Book Chapters and Other Papers

BACKGROUND: Angiotensin converting enzyme (ACE) inhibitors are known to improve clinical outcome and ventricular function in adults with heart failure. Infants with single-ventricle physiology show abnormalities in ventricular function as well as poor growth. The ability of an ACE inhibitor to preserve ventricular function and improve growth in these infants is unknown.

METHODS: The Pediatric Heart Network designed a randomized, double-blind trial to compare outcomes in infants with single-ventricle physiology receiving enalapril or placebo. Neonates < or =45 days old were eligible. The primary outcome is weight-for-age Z-score at 14 months of age. Secondary outcomes include other measures of somatic growth, laboratory and functional measures of heart failure, developmental indices, measures of ventricular size and function, and the relationship of the renin-angiotensin-aldosterone system genotype to the response to enalapril. The incidence and spectrum of adverse events will also be compared between treatment groups.

RESULTS: A total of 1,245 neonates were screened and 533 (43%) were eligible. The consent rate was 43%; 230 subjects were enrolled. Parental reluctance to …

The Value Of Implantable Cardioverter-Defibrillators In Managing Atrial Fibrillation, Daniel Frisch

Division of Cardiology Faculty Papers

Atrial fibrillation (AF) is associated with an increased risk of mortality as well as significant morbidity including bothersome symptoms, exacerbation of heart failure, and thromboembolic events. Explanations for the mortality risk are variable, but the majority opinion favors AF as a marker of reduced health status, especially cardiovascular health.

A Three-Year-Old Boy With X-Linked Adrenoleukodystrophy And Congenital Pulmonary Adenomatoid Malformation: A Case Report, Ibrahim Abdulhamid, Sermin Saadeh, Nedim Cakan

Wayne State University Associated BioMed Central Scholarship

Abstract

Introduction

X-linked adrenoleukodystrophy leads to demyelination of the nervous system, adrenal insufficiency, and accumulation of long-chain fatty acids. Most young patients with X-linked adrenoleukodystrophy develop seizures and progressive neurologic deficits, and die within the first two decades of life. Congenital or acquired disorders of the respiratory system have not been previously described in patients with X-linked adrenoleukodystrophy.

Case presentation

A 3-year-old Arabic boy from Yemen presented with discoloration of the mucous membranes and nail beds, which were considered cyanoses due to methemoglobinemia. He also had shortness of breath, fatigue, emesis and dehydration episodes for which he was admitted to …

Sequential Segmental Analysis., Robert H. Anderson, Girish S. Shirali

Manuscripts, Articles, Book Chapters and Other Papers

No abstract provided.

Fatal Transfusion Related Acute Lung Injury Following Coronary Artery By-Pass Surgery: A Case Report., Fauzia Ahmad Bawany, Hasanat Sharif

Section of Cardiothoracic Surgery

Background:Transfusion related acute lung injury (TRALI) is a potentially fatal Acute Lung Injury following transfusion of blood components. Hypotheses implicate donor-derived anti-human leukocyte antigen or granulocyte antibodies reacting with recipients' leukocytes, releasing inflammatory mediators. Lack of agreement on underlying cellular and molecular mechanisms renders improving transfusion safety difficult and expensive.

Case Presentation:

Literature search has not revealed any case of TRALI from Pakistan. We report the case of fatal TRALI in a 68 year old male who received blood products after coronary artery by-pass surgery.

Conclusion:

This article aims to create awareness about this complication and suggests that post …

Awareness Of The Risk Factors, Presenting Features And Complications Of Hypertension Amongst Hypertensives And Normotensives, Syed Nabeel Zafar, Saqib A. Gowani, Faria Amber Irani, Mohammad Ishaq

Section of Cardiology

OBJECTIVES: To assess the level of awareness with regards to risk factors, presenting features and complications of hypertension. Moreover, to Compare the level of awareness amongst patients (hypertensives) and nonpatients (normotensives) in Karachi, Pakistan.METHODS: This cross-sectional study was carried out on a random sample of 440 people (220-normotensives/220-hypertensives) using an interview based questionnaire. Data entry was performed on Epi-info v 6 and managed and analyzed on SPSS v 14. Proportions were calculated for categorical data, means and standard deviations were calculated for continuous data.RESULTS: Hypertensives had a higher mean awareness score than the normotensives (p

Pacemaker Patients' Perception Of Unsafe Activities: A Survey, Masooma Aqeel, Azam Shafquat, Nawal Salahuddin

Section of Cardiology

Background: Cardiac pacing is a recognized and widely used treatment for Patients presenting with bradycardia. Physicians expect Patients to return to normal activities almost immediately post implantation. However, Patients themselves may perceive interference to pacemaker function by various routine activities and devices, and hence continue to lead restricted, disabled lives. The aim of this study is to determine if routine activities are perceived by pacemaker Patients to interfere with their device function. Methods: A descriptive cross sectional survey was carried out on consecutive Patients at the pacemaker clinic at a public hospital in Karachi, Pakistan. A 47-question tool was developed …

Blood Pressure Lowering And Vasomodulator Effects Of Piperine, Syed Intasar Husain Taqvi, Abdul Jabbar Shah, Anwar Gilani

Department of Biological & Biomedical Sciences

This study was aimed to explore underlying mechanism(s) of cardiovascular effects of piperine. Intravenous administration of piperine caused a dose-dependent (1 to 10 mg/kg) decrease in mean arterial pressure (MAP) in normotensive anesthetized rats, the next higher dose (30 mg/kg) did not cause any further change in MAP. The fall in blood pressure (BP) was followed by small increase in MAP after each dose. In Langendorrf's rabbit heart preparation, piperine caused partial inhibition and verapamil caused complete inhibition of force and rate of ventricular contractions and coronary flow. In rabbit aortic rings, piperine inhibited high K(+) (80 mM) precontractions and …

Hiv-Associated Pulmonary Hypertension: Case Report, Jay Shavadia, S. Das, Gerald Yonga

Internal Medicine, East Africa

With the advent of highly active antiretroviral therapy, there has been a significant change in the epidemiology of pulmonary disease in HIV/AIDS. The relative prevalence of non-infectious manifestations is likely to rise. HIV associated pulmonary hypertension (HIV-PH), albeit low prevalence, is associated with significant morbidity and mortality. Presently, despite having scanty evidence on the management modalities of HIV-PH, evidence extrapolated from idiopathic pulmonary hypertension is being utilised to effectively manage some of these patients. Efforts should therefore be made to screen, diagnose and treat these patients. A case of a thirty year old female with HIV disease and severe pulmonary …