A CONFUSING CASE OF PNEUMONIA IN A PATIENT WITH HUMAN IMMUNODEFICIENCY VIRUS

Abstract

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: The incidence of acquired immunodeficiency syndrome (AIDS) related opportunistic infections has declined dramatically following the introduction of potent antiretroviral therapy. However, pulmonary infections remain a significant cause of morbidity and mortality (1). The spectrum of pulmonary disease that can affect patients with human immunodeficiency virus (HIV) is wide and includes opportunistic infection with many bacterial, fungal, viral, and parasitic organisms (2). Herein, we present a rare case of pneumonia caused by four different pathogens: Strongyloides Stercoralis, Pneumocystis Jirovecii (PCP), Cytomegalovirus (CMV) and Pseudomonas Aeruginosa. CASE PRESENTATION: A 65-year-old female from Mexico with a past medical history of HIV presents to the emergency department with subacute dyspnea, mild hemoptysis, melena, and fatigue. She was non-compliant with her anti-retroviral therapy. Her CD4 count was <20 cells/uL with a HIV PCR of 1,690,000 copies/mL. CBC demonstrated normocytic anemia (hemoglobin: 6.0 g/dl); hemolysis was excluded. Her Pa02 was 60 mmHg on room air. A computed tomography (CT) scan of the chest with contrast (image) revealed diffuse bilateral ground-glass opacities with diffuse interlobular septal thickening. Severe enteritis and colitis were seen on the CT abdomen/pelvis with contrast. The patient was empirically started on levofloxacin, metronidazole, intravenous (IV) trimethoprim-sulfamethoxazole and prednisone. Sputum cultures were positive for pan sensitive Pseudomonas Aeruginosa. Bronchoalveolar lavage (BAL), upper and lower endoscopy were performed. Blood and BAL CMV PCR were positive. She was subsequently started on IV ganciclovir. BAL PCP PCR was high. Several days later, numerous Strongyloides Stercoralis larvae were seen in the BAL and on the duodenal biopsy. Daily ivermectin was initiated. The patient progressed to septic shock requiring IV norepinephrine and her oxygenation worsened. The patient refused escalation of care and decided to proceed with comfort measures. The patient passed away within a few hours. DISCUSSION: Prior to the era of potent antiretroviral therapy, parasitic pulmonary infections were more commonly seen than they are today (2). Immunocompromised patients are at high risk for systemic strongyloidiasis which presents as either disseminated strongyloidiasis or hyper infection syndrome (3). Aside from HIV, our patient was empirically started on prednisone for PCP treatment which might have contributed to worsening systemic strongyloidiasis and therefore worsening clinical status. For severe disease, patients should be started on daily ivermectin along with empiric antibiotic therapy with activity against gram-negative bacteria. CONCLUSIONS: We describe a rare case of HIV related pneumonia caused by four different pathogens. Reference #1: Boyton RJ. Infectious lung complications in patients with HIV/AIDS. Curr Opin Pulm Med. 2005 May;11(3):203-7. Reference #2: Skalski JH, Limper AH. Fungal, Viral, and Parasitic Pneumonias Associated with Human Immunodeficiency Virus. Semin Respir Crit Care Med. 2016;37(2):257. Reference #3: Celedon JC, Mathur-Wagh U, Fox J, Garcia R, Wiest PM. Systemic strongyloidiasis in patients infected with the human immunodeficiency virus. A report of 3 cases and review of the literature. Medicine (Baltimore). 1994;73(5):256 DISCLOSURES: No relevant relationships by Ahmad Al-Shyoukh, source=Web Response No relevant relationships by Laith Derbas, source=Web Response No relevant relationships by Ashraf Gohar, source=Web Response No relevant relationships by Raed Qarajeh, source=Web Response No relevant relationships by Moustafa Younis, source=Web Response