Interesting case of TB and suspecting PCP confection in RVD patient

51yr old female patient came with

History of loose stools for 3 months 1 year back

History of cough with sputum 1 month 1 year back

Diagnosed Reteroviral disease and sputum for AFB positive 1 year back and she was started on ATT and completed course on June 2019 , was using ART- tenofovir efavirenz lamivudine but stopped 2 months back because of loose stools , vomitings and intermittent fever .

Now she presented with complaints of fever -high grade associated with chills and rigors ,loose stools and vomitings multiple episodes

O/e-

She is thin built, undernourished, tachypneic

Bp 90/60 mm hg

Spo2 - 66 at room air

Hr 140/min

Rr - 34/min

Cvs s1s2 

Rs BAE+ with BL basal crepts

Our provisional diagnosis was 

Oppurtunistic infection in k/c/o RVD  and post pulmonary TB 

? pulmonary TB reactivation 

Acute gastroenteritis 

Investigation :
Stool for c/s showed growth of normal intestinal Flora

We started her on supportive treatment and supsecting pneumocystis jiroveci SEPTRAN DS was added 

Chest x Ray was done and showed B/L basal ground glass opacities 

HRCT chest was done and it showed ground glass opacities over lower lobes of both lungs

Patient during hospital stay was oxygen dependant 

As x-ray  and HRCT and were more in favour of PCP and as patient was hypoxic we  started on steroids ,

but on day 3 of admission patient developed severe tachypneic with falling saturations we intubated her and kept on IPPV mode ,ABG showed picture of T2 respiratory failure -  severe respiratory acidosis,patient BP ,PR was not recordable and CPR initiated and despite all resuscitative efforts patient couldn't not be revived back .

Her sputum for CBNAAT came to be Rifampicin resistant TB !!!!,though we couldn't get report before she expired .