Just Another Office Visit for Shortness of Breath…

Abstract

INTRODUCTION: Opportunistic infections in the HIV population have declined since the advent of highly active antiretroviral therapy (HAART). However, Pneumocystis jirovecii (PCP) occurs in those not yet diagnosed with HIV, those not receiving medical care, those not receiving PCP prophylaxis, and those not taking or not responding to HAART. CASE PRESENTATION: A thirty-nine year old African American female, with no significant past medical history, presented to the office with cough and shortness of breath. She was healthy until two months prior, when she developed dyspnea, chest discomfort, and fever. She was diagnosed with pneumonia, treated with azithromycin, budesonide, formoterol, and albuterol. Her symptoms resolved. Six days prior to presentation she experienced shortness of breath, chest discomfort, and fevers. She denied sick contacts, pets, environmental exposure, tobacco abuse/exposure, high risk sexual behavior, and drug use. She was tachycardic, tachypneic, afebrile, with an oxygen saturation of 83% on room air. Her breath sounds were diminished with few scattered wheezes. She was directly admitted. Arterial blood gas revealed pH7.46 PaCO2 36 torr, PaO2 69 torr, bicarbonate of 25 mmol/L and alveolar-arterial oxygen gradient of 123 mm Hg on 3.5 liters of oxygen per minute via nasal cannula. Other blood tests, including a connective tissue disease panel, were negative. CT scan showed diffuse ground glass opacities. On bronchoscopy no endobronchial lesions were seen. BAL was negative for bacteria and mycobacteria. Silver stain, giemsa stain, and immunofluorescence were positive for pneumocystis. HIV quantitative PCR 400437 copies/mL. DISCUSSION: In the early 1970's there were less than 100 cases of PCP reported in the United States. Following the AIDS epidemic in 1982 the number of cases peaked to 20,000 per year. The reports declined in the early 1990's due to the widespread use of PCP prophylaxis, and further decreased with the advent of HAART therapy in 1995. Despite the significant decline, PCP remains the most common and life threatening opportunistic infection, one must remain vigilant of PCP in the population. CONCLUSIONS: In the setting of hypoxia and diffuse ground glass opacities one must always consider PCP in the differential diagnosis.