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Chest Infections |

An Unusual Finding in a 45-Year-Old Man With AIDS, Bilateral Pulmonary Infiltrates, and Respiratory Failure FREE TO VIEW

Daryl Connolly, MD; Stephen Baldassarri, MD; Rebecca Baldassarri, MD; Carrie Redlich, MPH
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Yale University Department of Internal Medicine/Section of Pulmonary, Critical Care, and Sleep Medicine, New Haven, CT


Chest. 2015;148(4_MeetingAbstracts):108A. doi:10.1378/chest.2264996
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Abstract

SESSION TITLE: Chest Infections II: Student Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Pulmonary complications remain a major contributor of morbidity and mortality among individuals with AIDS. There are a wide range of infectious and non-infectious disorders that are associated with severely immunocompromised patients. This population may provide particular challenges for treatment due to a broad array of differential diagnoses.

CASE PRESENTATION: A 45-year-old Haitian man with no known medical conditions presented with progressive dyspnea and weight loss after failed outpatient treatment for community acquired pneumonia. On exam, he was afebrile and tachypneic with increased work of breathing. He had lymphadenopathy and pulmonary exam disclosed bilateral crackles and wheezing. His chest CT scan revealed bulky lymphadenopathy with multiple pulmonary nodules and ground glass halos (figure 2). He tested positive for HIV (CD4 count 7) and was hypoxemic (PaO2 = 56 on RA) . Empiric treatment for presumed PCP was initiated but developed worsening respiratory failure requiring mechanical ventilation. On the first hospital day, blood cultures and CSF grew cryptococcus neoformans, and amphotericin/flucytosine were started. Hypotension developed and vasopressor support was initiated. Bronchoscopy with BAL, transbronchial biopsies, and EBUS were performed. Cultures of tissue, fluid, and cytology showed both cryptococcus and histoplasma. The patient completed 14 days of amphotericin/flucytosine and was transitioned to oral voriconazole. Antiretroviral therapy was not started prior to discharge to prevent a potentially fatal immune reconstitution syndrome. He improved and was discharged from the hospital in stable condition.

DISCUSSION: This case demonstrated the wide range of possible infectious etiologies in severely immunocompromised patients with AIDS. This patient was unaware of his HIV infection and was diagnosed with both disseminated cryptococcal infection and pulmonary histoplasmosis. Bronchoscopy was crucial in this case as patients with AIDS require a more aggressive workup and can have multiple infections which require a conclusive diagnosis. Co-infection with these two fungal organisms appears to be quite rare, reported in less than a dozen cases after a literature review. Cryptococcus is the most common fungus in immunocompromised hosts and has a high propensity to disseminate from the lungs to the CNS. Histoplasmosis is thought to have a geographic preference (Ohio and Mississippi River Valleys) and infection can range from mild pulmonary symptoms to cavity lung disease.

CONCLUSIONS: Although rare, multiple concomitant fungal infections may occur in patients with AIDS. This case demonstrates the need to consider the likelihood of multiple co-existing infections in severely immunocompromised hosts, particularly those with advanced AIDS.

Reference #1: Corti M, Palmero D, Eiguchi K (2009) Respiratory infections in immunocompromised patients. Curr Opin Pulm Med 15: 209-217.

DISCLOSURE: The following authors have nothing to disclose: Daryl Connolly, Stephen Baldassarri, Rebecca Baldassarri, Carrie Redlich

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