SHM Converge Scientific Abstract ePoster Gallery-Beyond Community-Acquired Pneumonia: A Detour to PJP and Undiagnosed Hiv in a 70-Year-Old

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This case describes a 70-year-old woman who presented with 3 days of progressive shortness of breath, anorexia, confusion, and weakness after a fall. She had a history of hypertension, dyslipidemia, and tobacco use. On arrival she was critically ill, hypotensive, profoundly hypoxic, cyanotic, and had minimal air movement with wheezing.<br /><br />Initial workup showed imaging concerning for multifocal pneumonia, including bibasilar opacities on chest X-ray and CT findings of confluent perihilar ground-glass opacities, septal thickening, and dependent consolidations. She was admitted to the MICU and treated empirically for severe community-acquired pneumonia with ceftriaxone, azithromycin, and prednisone. However, after 72 hours she showed no meaningful improvement, prompting reassessment.<br /><br />Because of the poor response to standard CAP therapy and imaging features suggestive of an alternate process, clinicians evaluated for immunocompromise. She was found to be HIV-1 positive. A non-bronchoscopic bronchoalveolar lavage sample was positive for Pneumocystis jirovecii pneumonia (PJP) by PCR. She was started on bictegravir/emtricitabine/tenofovir alafenamide (Biktarvy) for HIV and trimethoprim-sulfamethoxazole plus prednisone for PJP.<br /><br />Her course was complicated by insomnia, tremors, hyperactive delirium, hyperkalemia, and acute kidney injury, highlighting the risks of high-dose corticosteroids and other treatments in older adults. At 6-month infectious disease follow-up, she had returned to baseline functional status, was on room air, had an undetectable HIV viral load, and a CD4 count of 187 cells/μL, and remained on ART and PJP prophylaxis.<br /><br />The key teaching points were: reassess diagnoses if pneumonia does not improve within 48–72 hours; do not exclude HIV testing based on age or perceived risk; and remain vigilant for delirium, electrolyte abnormalities, and deconditioning in older hospitalized patients.

Asset Subtitle

Austin M. Keller

Meta Tag

Author List Austin M. Keller, Constanza Menendez Alurralde, Marion v. Stanley, Niraj v. Lawande

Category Clinical Vignettes

Concept Community-Acquired Pneumonia

Concept Pneumocystis jirovecii pneumonia

Concept HIV Screening

Concept Trimethoprim-sulfamethoxazole

Concept Treatment Failure

Distinguished Non-Finalist

Presenter Organization Northwestern University Feinberg School of Medicine - Department of Medicine

Presenting Author Austin M. Keller

Track Adult

Keywords

Pneumocystis jirovecii pneumonia

HIV-1

multifocal pneumonia

shortness of breath

bronchoalveolar lavage

trimethoprim-sulfamethoxazole

bictegravir emtricitabine tenofovir alafenamide

older adult delirium

community-acquired pneumonia

immunocompromise

Community-Acquired Pneumonia

Pneumocystis jirovecii pneumonia

HIV Screening

Trimethoprim-sulfamethoxazole

Treatment Failure