case 2-2011: a 34 year-old man with fever and abdominal pain

a 34-year-old hiv positive-man was admitted to the hospital due to fever and abdominal pain. constant and generalized abdominal pain started 3 months prior to admission (pta) in upper quadrants of abdomen followed by mild odynophagia, early satiety and more than 20 kg weight loss since then. intermittent fever begun 7 days pta and cough, sputum and dyspnea started since 5 days pta. his general condition deteriorated and became drowsy 2-3 days pta, so was referred to our center by patient's accompanies. patient was a known case of intravenous heroin and a recent case of crack user. he smoked cigarette more than 2 packs a day and drinks alcohol occasionally. on admission day he looked toxic and lethargic. bp:95/60 mmhg, pr:128/min, rr:28/min, temperature:41.5°c and o2 saturation in room air :92%. physical exam (p/e) of skin revealed multiple tattoos and some scars. head and neck p/e were normal. p/e of heart showed tachycardia without murmur. there were fine crackles in lower zone of left lung associated with generalized wheezing. on abdominal examination, there was abdominal distension with shifting dullness, hepatomegaly (8cm below costal margin) and generalized tenderness without guarding or rebound. there was two plus pitting edema in lower extremities. peripheral lymphadenopathy was not detected.patient was admitted to intensive care unit. abdominal ultrasound showed liver enlargement with two large heterogeneous mass. common bile duct and portal vein diameters were normal. gall bladder was normal and moderate ascites was detected. in transthoracic echocardiography (tte) ejection fraction was normal and there was no vegetation. in upper gi endoscopy esophageal candidiasis was seen. colonoscopy was unremarkable, urine analysis was normal, and urine culture and blood culture results were negative.