DIAGNOSTIC UNCERTAINTY IN A STEROID-RESPONSIVE LUNG DISEASE IN AN IMMUNOCOMPROMISED PATIENT

Case Presentation: A 51-year-old female with a history of HIV on Biktarvy and ESRD on hemodialysis presented with progressive dyspnea. Three weeks prior to admission, she developed a non-productive cough with associated chest pain, dyspnea, headache, and subjective fevers and chills. She denied nausea, vomiting, orthopnea, lower extremity swelling, or weight change. Family history was notable for a daughter with repeated pulmonary infections due to unclear etiology. Patient was a past smoker with continued exposure to secondhand smoke and reported no recent travel.On admission, patient had decreased breath sounds and mild crackles in bilateral lower lobes without peripheral edema. Labs showed mild troponin and BNP elevation. Chest X-ray indicated possible pulmonary edema, and CTPE demonstrated severe multifocal pneumonia with right greater than left pleural effusions and atelectasis. She underwent diuresis and dialysis for presumed volume overload without clinical improvement, so Pulmonary was consulted. Bronchoalveolar lavage (BAL) was performed and showed normal mucosa with thin, frothy secretions throughout the tracheobronchial tree without diffuse alveolar hemorrhage (DAH). BAL cell counts demonstrated 13% eosinophils and cultures grew Strep. mitis, S. oralis, and Neisseria subflava.Infectious Disease was consulted, and testing—including an extended respiratory Biofire panel, Aspergillus, P. jirovecii, cryptococcal antigen, MTB PCR, AFB, and fungal/blood cultures—was negative. Rheumatologic work-up was also negative except for rheumatoid factor and MI-2 beta antibody which were mildly positive. Transthoracic echo was unremarkable. Following the unrevealing infectious workup, the leading differential from the Pulmonary team was cryptogenic organizing pneumonia (COP). Patient was empirically started on solumedrol 40mg twice daily. She rapidly improved and was weaned entirely off of supplemental oxygen within 3 days. Repeat CT imaging 3 days after solumedrol initiation showed dramatic improvement of prior multifocal consolidations. Patient was discharged in stable condition with scheduled oral steroid taper and Pulmonary follow-up.

Discussion: This case helps to expand the differential in a patient with ESRD and HIV presenting with dyspnea and radiographic infiltrates. Initial leading differentials based on her history, clinical presentation, and imaging were hypervolemia and infection. However, patient did not improve with diuresis or dialysis and infectious work-up was negative. Autoimmune etiologies were in the differential but lower given lack of systemic manifestation. The two leading diagnoses in this case based on BAL findings and her clinical improvement on steroids are COP and acute eosinophilic pneumonia (AEP). Both conditions are usually steroid responsive. AEP shows rapid radiographic improvement while COP has delayed radiographic response. Given her concurrent swift radiographic and clinical improvement, the most likely diagnosis in this case is AEP despite BAL only demonstrating 13% eosinophils. In addition, the lack of alveolar lymphocyte predominance and COP triggers in this patient favor AEP pattern.

Conclusions: This case highlights the diagnostic complexity of atypical dyspnea in immunocompromised patients, emphasizing the need for a systematic, multidisciplinary approach that broadens the differential beyond infectious causes to include non-infectious and inflammatory etiologies for timely and effective management.