Case Presentation: Case presentationA 47 yo female with a history of hypertension, obesity, and prediabetes presented to the emergency department of a community hospital with a 2 week history of a nonproductive cough and generalized weakness. Her chest x-ray showed bilateral patchy airspace opacities. Chest CT PE protocol was negative for pulmonary embolus, but showed extensive parenchymal abnormalities. SARS-CoV-2 nasopharyngeal PCR was obtained in the emergency department; however, the result was not available for 48 hours. Tests commonly associated with COVID-19 including LDH, CRP, and D-dimer were elevated. Since COVID-19 was strongly suspected, dexamethasone was initiated. Within 24 hours of initiation of dexamethasone, she developed rapidly increasing oxygen requirements and required endotracheal intubation with mechanical ventilation. Her 4th generation HIV test returned positive.She was extubated on hospital day 2 and was transferred to our tertiary medical center for the care of presumed COVID-19 in the setting of newly-diagnosed human immunodeficiency virus (HIV) infection. On arrival, her temperature was 36.9˚C and her oxygen saturation level was 87% on 80% high flow oxygen. Her HIV-1 viral load was 50,800 copies/mL, and CD4 count was 5/µL/1.5% (normal 404 – 1,612/µL). Given concern for opportunistic infection in the setting of newly diagnosed HIV infection, testing for Pneumocystis jirovecii (BAL PCR), aspergillus galactomannan antigen (BAL), serum toxoplasma IgG and IgM, AFB blood culture, and serum cryptococcal antigen was ordered. BAL specimens for AFB and fungal cultures were also ordered. (1,3)-beta-D-glucan (Fungitell) was elevated at 444 pg/mL. Pneumocystis jirovecii polymerase chain reaction (PCR) was positive from endotracheal tube aspirate and bronchoalveolar lavage (BAL), but testing for other pathogens was negative. Pathology from her BAL GMS stain did not show Pneumocystis or other fungal forms; however, it did reveal a few alveolar casts, which are suggestive of Pneumocystis. Coronavirus PCR testing returned negative on hospital day 2. Sulfamethoxazole-trimethoprim (Bactrim DS 800 mg-160 mg) 2 tablets q 8 h and transition to PCP treatment dose prednisone, with plans for 21 days of treatment, was recommended by the Infectious Diseases service. She currently remains hospitalized on high flow oxygen.

Discussion: DiscussionDue to the utilization of effective antiretroviral therapy and to a lesser degree the use of prophylaxis, the incidence of Pneumocystis jirovecii pneumonia (PCP or PJP) has dramatically decreased over the last 10-20 years. PCP continues to be an important cause of opportunistic infections in patients with HIV infection who have CD4 counts < 200/µL, 80 pg/mL are suggestive of PCP.

Conclusions: ConclusionAlthough COVID-19 is currently a common cause of acute respiratory illness, it is important to recognize that other pathogens (many of which are treatable) can cause severe respiratory infections, particularly in those who are immunocompromised.