Chest Infections |

Severe Pneumocystis jiroveci Pneumonia in a HIV Patient With Normal CD4 Count - Role of CMV Coinfection? FREE TO VIEW

Vinay nidadavolu, MBBS; Manikya kuriti, MBBS; Venkata Buddharaju, MBBS
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univ of connecticut, hartford, CT

Chest. 2013;144(4_MeetingAbstracts):245A. doi:10.1378/chest.1704105
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SESSION TITLE: Infectious Disease Student/Resident Case Report Posters II

SESSION TYPE: Medical Student/Resident Case Report

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

INTRODUCTION: Pneumocystis Jiroveci pneumonia (PCP) is a common opportunistic infection seen in immune-compromised hosts. While its incidence in immune-competent hosts has been described, the risk factors for it have not been identified yet. We report a case of severe PCP in a HIV patient with a normal CD4 count along with a CMV co-infection that progressed to pneumo-mediastinum, pneumatoceles and severe respiratory failure.

CASE PRESENTATION: A 47-year-old, African-American man with longstanding HIV suppressed on a HAART. He presented to his ID doctors office with cough, subjective fevers and dyspnea on exertion. A chest x-ray showed peripheral air space opacities. An LDH was 150. His CD4 count was 379. He was started on Levofloxacin for a presumed community-acquired pneumonia. He came back to the clinic for worsening dyspnea. A repeat chest x-ray showed worsening infiltrates. He was admitted to the hospital for further work up. His labs still showed a normal LDH modest rise in the white count to 14000. The HIV viral load was 103. He was eventually intubated the next day. CT chest showed a symmetric, peripheral, bilateral, multifocal consolidation. A Bronchoscopy was done that showed a relatively normal mucosa. Pneumocystis and CMV were isolated in the BAL. The patient was started on Bactrim, Ganciclovir as well as intravenous steroids. His LDH started to rise on Day 9 from the initial symptoms to high 200s and on Day 15 to 500s. Follow-up CT chest showed a cluster of pneumatoceles in left upper lung and in the lung bases bilaterally, the largest left lung base measured 9.3 x 8.3 x 7.2. Pneumo-mediastinum also was noticed. Patient was watched carefully for spontaneous pneumothorax and was safely extubated after 5 days.

DISCUSSION: PCP pneumonia is a disease not limited only to immune-compromised hosts. Co-infection with CMV has been shown in a few case studies as well as murine models to increase the incidence as well as severity of PCP infection from immune-modulation. While LDH levels have always been historically elevated with PCP. Its sensitivity is debatable and further investigations are certainly needed to find other more sensitive non-invasive tests

CONCLUSIONS: 1) Presence of CMV co-infection could increase the risk and severity of PCP. 2) Serum LDH level is not a sensitive test to rule out PCP.

Reference #1: A Pneumocystis jirovecii pneumonia outbreak in a single kidney-transplant center: role of cytomegalovirus co-infection. Pliquett RU et al; Eur J Clin Microbiol Infect Dis. 2012 Sep;31(9):2429-37.

Reference #2: A murine model of dual infection with cytomegalovirus and Pneumocystis carinii: effects of virus-induced immunomodulation on disease progression. Qureshi MH et al. Virus Res. 2005 Dec;114(1-2):35-44.

Reference #3: Serum indicators for the diagnosis of pneumocystis pneumonia. Tasaka S et al. Chest. 2007 Apr;131(4):1173-80.

DISCLOSURE: The following authors have nothing to disclose: Vinay nidadavolu, Manikya kuriti, Venkata Buddharaju

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