Concomitant Pneumocystis Jirovecii Pneumonia and Cytomegalovirus Pneumonitis as Initial Presentation of Acquired Immune Deficiency Syndrome

Document Type

Conference Proceeding

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Publication Title

American Journal of Respiratory Care and Critical Care Medicine


Introduction: We present a case of a 45 yom who was diagnosed with HIV/AIDS presenting with refractory septic shock who waslater found to have PJP pneumonia along with CMV pneumonitis. In the setting of concomitant PJP and CMV infections it isdebated if CMV treatment is needed, due to increased nephrotoxic effects of Bactrim and ganciclovir. Description: A wellappearing 45 year old male presented to a community emergency department with complaints of dyspnea for one month. Thepatient was found to have mild anemia, lymphopenia, and a chest x-ray showing diffuse interstitial markings. A clinical diagnosisof atypical pneumonia was made and the patient was discharged with a prescription for doxycycline. Within four days, the patientwas admitted to an academic medical center for respiratory distress where he was intubated due to respiratory failure. Initialexam and work up showed a yeast infection of the groin, a metabolic acidosis, leukocytosis, acute kidney injury, elevated lactate,chest x-ray with worsening interstitial opacities, and a negative Covid-19 and influenza tests. A central venous catheter wasplaced for resuscitation and medication therapy. The patient was started on broad spectrum antibiotics, vasopressors, and stressdose steroids. HIV serology and other tests for opportunistic infections were ordered. The patient was found to be HIV positivewith an absolute CD4 count of 42/mm3. Bronchial alveolar lavage cultures were positive for CMV (2,000 IU/mL) andpneumocystis jirovecii (PJP PCR +). Intravenous ganciclovir was started in the setting of CMV, however it should be noted thatganciclovir was started 48 hours after initiation of broad spectrum antimicrobial agents. The patient continued to improve with 21days of PJP treatment and 14 days of CMV treatment. Forty-five days after hospital admission the patient was discharged ingood condition with prescriptions for HAART and opportunistic infection prophylaxis. Discussion: This case illustrates theimportance of considering treatment for CMV pneumonitis in patients with HIV/AIDs. It is not uncommon to isolate CMV from aBAL in patients with HIV/AIDS and historical data shows no association with increased mortality. However recent data signals acorrelation with worsened outcomes when a CMV BAL level is greater than 1,000 IU/mL in the setting of HIV/AIDS. In this case,patient improvement was observed with CMV treatment. Recognition of CMV is critical to the initiation of appropriate therapy toprevent poor outcomes in this population.





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International Conference of the American Thoracic Society, May 19-24, 2023, Washington DC