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Pneumocystis Pneumonia in Acute HIV Infection FREE TO VIEW

Andrew Tomlinson, MD; James Fox, MD; Brandon Swartz, MD; Rosechelle Ruggiero, MD
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UT Southwestern, Dallas, TX

Chest. 2013;144(4_MeetingAbstracts):188A. doi:10.1378/chest.1702375
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SESSION TITLE: Infectious Disease Case Report Posters III

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Pneumocystis jirovecii pneumonia is a common opportunistic infection in patients with the acquired immunodeficiency syndrome (AIDS). However, it most commonly occurs in the setting of a T-helper cell count (CD4+) less than 200 cells per cubic millimeter.1

CASE PRESENTATION: We report the case of a 47-year-old man who was diagnosed with pneumocystis pneumonia during what was suspected to be an acute infection with the human immunodeficiency virus (HIV). He presented to the emergency department with a 2-week history of fever, cough, and progressive dyspnea. He had no significant prior medical history. He was febrile to 38.2 degrees Celsius, tachycardic, and tachypneic and his physical examination was otherwise only notable for bilateral lower lung field rales. A chest radiograph (Figure 1) showed diffuse bilateral patchy opacities and the patient was admitted to the hospital for treatment of community-acquired pneumonia. He was initially treated with ceftriaxone and azithromycin. One day after admission, an HIV-antibody test returned positive and treatment for pneumocystis pneumonia with trimethoprim, sulfamethoxazole, and prednisone was added. Two days after admission his CD4+ count was noted to be 551 and a fiberoptic bronchoscopy was performed. Direct fluorescent antibody testing for P. jirovecii performed on the bronchoalveolar lavage specimen was positive and Grocott’s methenamine silver (GMS) staining of the transbronchial biopsies (Figure 2) showed the characteristic cup-shaped cysts of P. jirovecii.

DISCUSSION: Acute HIV infection is known to cause transient CD4+ lymphocytopenia,2 but this has only rarely been associated with opportunistic infections.3 Here we report the case of a man suspected to have acute HIV infection on the basis of constitutional symptoms, elevated transaminases, and newly diagnosed HIV infection with a preserved CD4+ count that was diagnosed with pneumocystis pneumonia.

CONCLUSIONS: An opportunistic infection should not be ignored as a possible etiology of illnesses in patients with newly diagnosed HIV infection. Acute HIV infection is associated with significant immunosuppression that does not correlate with the patient’s CD4+ count.

Reference #1: Phair J, Muñoz A, Detels R, Kaslow R, Rinaldo C, Saah A. The risk of Pneumocystis carinii pneumonia among men infected with human immunodeficiency virus type 1. NEJM 1990; 322:161-5.

Reference #2: Mattapallil JJ, Douek DC, Hill B, Nishimura Y, Martin M, Roederer M. Massive infection and loss of memory CD4+ T cells in multiple tissues during acute SIV infection. Nature 2005; 434:1093-7.

Reference #3: Vento S, Di Perri G, Garofano T, Concia E, Bassetti D. Pneumocystis carinii pneumonia during primary HIV-1 infection. Lancet 1993; 342:24-5.

DISCLOSURE: The following authors have nothing to disclose: Andrew Tomlinson, James Fox, Brandon Swartz, Rosechelle Ruggiero

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