An 80-year-old woman presenting with cough, weight loss, and hypoxemia was ultimately diagnosed with advanced HIV-1 infection complicated by Pneumocystis jirovecii pneumonia and cryptococcal pneumonia, according to a case record published in the New England Journal of Medicine.
The patient, who had been active and independent, developed a productive cough and constitutional symptoms over an 8-week period before hospital admission. On presentation, her oxygen saturation was 83% on ambient air, and chest CT revealed diffuse ground-glass opacities in both lungs. Initial testing for common respiratory pathogens was negative, and empirical treatment for community-acquired pneumonia did not lead to improvement.
"Patients with P. jirovecii pneumonia present with cough, dyspnea, and fever over the course of days to weeks, and they can also present with weight loss and anorexia," the researchers wrote, noting that characteristic imaging findings include bilateral ground-glass opacities.
Given the patient's prolonged symptoms, hypoxemia, recent herpes zoster infection, and travel and sexual history, clinicians pursued HIV testing. HIV-1 antigen-antibody testing was reactive, with confirmatory testing establishing advanced infection. Laboratory evaluation showed an HIV-1 viral load of 223,000 copies per milliliter and a CD4 cell count of 33 per microliter.
Bronchoalveolar lavage confirmed P. jirovecii infection, and fungal cultures unexpectedly grew Cryptococcus neoformans. Although serum cryptococcal antigen tests were negative, the researchers noted that "cryptococcal antigen testing is most sensitive for disseminated or central nervous system disease and may be negative in cases of isolated pulmonary infection when the fungal burden is low."
The final laboratory diagnosis was advanced HIV-1 infection with concurrent P. jirovecii pneumonia and cryptococcal pneumonia. Treatment included high-dose trimethoprim-sulfamethoxazole with adjunctive glucocorticoids, fluconazole for cryptococcal infection, and antiretroviral therapy after central nervous system disease was excluded.
The patient responded favorably, with complete resolution of shortness of breath and subsequent viral suppression to undetectable levels.
"P. jirovecii pneumonia remains one of the leading opportunistic infections among persons living with advanced HIV infection, especially those with previously undiagnosed HIV infection," the researchers wrote.
The case underscores the importance of HIV risk assessment and screening in older adults, according to the researchers. They highlighted that in the United States, 41% of persons living with HIV infection were 55 years of age or older, and older adults are more likely to receive a diagnosis at an advanced stage of disease.
The final diagnosis was Pneumocystis jirovecii pneumonia and cryptococcal pneumonia in the setting of advanced HIV-1 infection.
Disclosure forms can be found in the published case report.