A 72 year old Caucasian man presented to the emergency room (ER) with dyspnea on exertion and dry cough for two weeks. He had a remote smoking history. Physical examination was unremarkable. Arterial blood gas was consistent with hypoxemia but X‐ray and computerized tomography (CT) of chest were inconclusive. Cardiac workup was unremarkable. The patient was diagnosed with possible chronic obstructive pulmonary disease (COPD) exacerbation. He was treated with bronchodilators and steroids therapy and subsequently discharged home. Outpatient pulmonary function tests demonstrated decrease in diffusion capacity without evidence of COPD. The patient did better over the next few months. Unfortunately, the patient returned to ER three months later with similar complaints. He was hypoxemic, in respiratory distress, a repeat chest x‐ray (CXR) now showed bilateral infiltrates. A diagnosis of community acquired pneumonia was made and antibiotics were administered. CT chest was consistent with diffuse bilateral ground glass opacification which raised suspicion for Pneumocystis jirovecii pneumonia (PCP). Intravenous methylprednisolone and trimethoprim‐sulfamethoxazole (TMP‐SMX) were initiated. Infectious work up for fungal and bacterial etiologies was unremarkable. Human immunodeficiency virus (HIV) screen tested positive, confirmed with western blot. CD4 count was 17 cells/mm3. Diagnosis of PCP was confirmed on bronchoalveolar lavage. Highly active antiretroviral therapy was initiated and the patient was discharged home in stable condition. In retrospect, a detailed sexual history revealed that the patient had unprotected sex with multiple sexual partners. The patient is currently following with infectious diseases clinic for HIV.
Dyspnea is one of the top five causes of ER visits in adult population. The differential is broad including cardiovascular, pulmonary and musculoskeletal etiology, to mention a few. Special attention should be given in finding the right diagnosis as this could represent a life‐threatening process. Although rare, HIV can be diagnosed late in elderly presenting with opportunistic infections. PCP should be considered in a patient presenting with hypoxia and bilateral pulmonary infiltrates, even in an immunocompetent host. CXR can be normal in up to 25% of patients. Diagnosis is made with immunofluorescent staining of specimens obtained by sputum induction or bronchoalveolar lavage. TMP‐SMX remains the preferred regimen for therapy of PCP. The mortality of Pneumocystis pneumonia in HIV‐infected patients ranges from 10 to 20%. Therefore, early diagnosis and aggressive treatment is of prime importance.
Our case highlights importance of obtaining sexual history in all patients irrespective of their age. Obtaining a careful sexual history is often ignored in geriatric population presenting with dyspnea which can lead to misdiagnosis.