SESSION TITLE: Miscellaneous Cases
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Wednesday, October 28, 2015 at 11:00 AM - 12:15 PM
INTRODUCTION: Diffuse pulmonary alveolar hemorrhage is an unusual pulmonary manifestation in patients with HIV disease. When it occurs, it is attributable to generalized coagulopathy, mycobacterium infection or rarely Pnuemocystis Jerovici infection. We present a case of an AIDS patient who succumbed to an uncommon pathogen.
CASE PRESENTATION: A 37-year-old male with recent diagnosis of AIDS and toxoplasmosis, presented with a witnessed seizure. Evaluation was significant for psychomotor slowing, diffuse hypopigmented macular rash and refractory hypotension. During the intensive care unit course, he developed hemoptysis, raising concern for tuberculosis, which was ruled out by sputum smears for acid fast bacilli. His chest CT chest showed several nodular densities in the lung apices and diffuse ground glass opacities (Figure 1). He was empirically started on steroids for presumed pneumocystis jerovici pneumonia(PJP). He was also started on foscarnet for empiric CMV pneumonitis as his CMV serology was positive. Bronchoscopy demonstrated frank bloody return from all lung lobes. BAL was negative for pneumocystis. Cytology was positive for strongylodosis (Figure 2) and so he was started on ivermectin. He developed persistent vomiting and abdominal distention due to partial small bowel obstruction, requiring endotracheal intubation for airway protection. Nasogastric tube aspirate was positive for strongyloides on cytology. Despite aggressive management of diffuse alveolar hemorrhage and small bowel obstruction- both thought to be due to strongyloidosis, the patient expired on hospital day 24.
DISCUSSION: Diffuse alveolar hemorrhage has been well described in connective tissue disorders, but no so much in pulmonary infections. Under conditions associated with immunocompromise, the autoinfective cycle of strongyloides can amplify into a potentially fatal hyperinfection syndrome. Hyperinfection in HIV patients have been described in those who received steroids for PJP pneumonia or as a part of chemotherapy for lymphoma. It is unsure whether anthelminthic therapy induces parasite migration.
CONCLUSIONS: A high degree of suspicion for uncommon pathogens is necessary while treating lung conditions in HIV AIDS patients.
Reference #1: Strongyloides stercoralis in the Immunocompromised Population Paul B. Keiser and Thomas B. Nutman* CLINICAL MICROBIOLOGY REVIEWS, Jan. 2004, p. 208-217 DOI: 10.1128/CMR.17.1.208-217.2004
DISCLOSURE: The following authors have nothing to disclose: Navitha Ramesh, David Nesheim, Jason Filopei, Michael Bergman, Sarun Thomas, Samuel Acquah
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