Cases from the Osler Medical Service at Johns Hopkins University

Presenting features A 40-year-old man with human immunodeficiency virus infection (CD4 count, 694/μL) and a history of sickle cell anemia was admitted for pain management after a right iliac wing fracture sustained in an assault. He denied recent fevers or respiratory symptoms. His medical history was remarkable for repeated vaso-occlusive crises and episodes of the acute chest syndrome, with resultant pulmonary hypertension and right-side heart failure. His physical examination was most notable for fever as high as 38.2°C, cervical and axillary adenopathy (2 cm), elevated jugular venous pressure, cardiomegaly, and hepatomegaly. His hematocrit was 19.5%, with a mean corpuscular volume of 91 fL; the platelet count was 176 000/μL; and the leukocyte count was 15 000/μL. He underwent a computed tomographic scan of the chest, abdomen, and pelvis (Figure 1), which revealed discrete lesions of low attenuation in the liver, the largest being 4.5 cm in diameter, and autoinfarction of the spleen. Figure 1. Computed tomographic scan of the chest, abdomen, and pelvis revealing discrete lesions of low attenuation in the liver and autoinfarction of the spleen. What is the diagnosis?