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Once bitten, twice shy
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  1. B D Fox1,
  2. S Morgenstern2,
  3. A Grubstein3,
  4. S Pitlik4,
  5. M R Kramer1
  1. 1
    Pulmonary Institute, Rabin Medical Center, Beilinson Campus, Petach Tiqwa, Israel
  2. 2
    Pathology Institute, Rabin Medical Center, Beilinson Campus, Petach Tiqwa, Israel
  3. 3
    Department of Radiology, Rabin Medical Center, Beilinson Campus, Petach Tiqwa, Israel
  4. 4
    Internal Medicine C, Rabin Medical Center, Beilinson Campus, Petach Tiqwa, Israel
  1. Correspondence to Dr B D Fox, Pulmonary Institute, Rabin Medical Center (Beilinson Campus), Petach Tiqwa 49100, Israel; benfox{at}post.tau.ac.il

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Clinical presentation

A 46-year-old man of Ethiopian origin was admitted to hospital in 2008 for investigation of cough, increasing dyspnoea and weight loss over several weeks. He was known to be HIV positive. He had a history of several opportunistic infections, including Cryptosporidium diarrhoea, tuberculosis, Mycobacterium avium complex and Pseudomonas pneumonia. He had also been treated in 2005 for visceral leishmaniasis with liposomal amphotericin. His prescribed medication included trimethoprim–suxamethoxazole, clarithromycin, efarinez, lamivudine, zidovudine and folic acid. His compliance with highly active antiretroviral therapy (HAART) was known to be poor.

On physical examination he was afebrile. Aside from moderate tachypnoea (24 respirations/min), his vital signs were normal. General examination showed cachexia and marked parotid swelling. The abdomen was non-tender with hepatosplenomegaly. Cardiac/respiratory examination was …

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