Clinical Scenario or Case: A 66-year-old woman with HTN, DM, and HLD presented in January 2024 with cough, shortness of breath, and weight loss after failed outpatient treatment for pneumonia. Imaging revealed bilateral ground-glass opacities. Initially managed for atypical pneumonia with steroids and Bactrim, she improved and was discharged. In August, she returned with worsening respiratory symptoms, ultimately diagnosed with PCP pneumonia, CMV infection, and HIV/AIDS. She denied recent sexual activity and had no documented HIV testing. Further history revealed a single unprotected sexual encounter with her ex-husband years after their divorce. She was unaware of his HIV status. Despite maximal therapy, she succumbed to progressive respiratory failure and sepsis.
Evidence/Literature Review: PCP pneumonia remains a leading opportunistic infection among untreated HIV patients. According to CDC data, delayed HIV diagnosis significantly increases mortality from opportunistic infections.¹ Studies confirm that undiagnosed HIV remains common in older adults and non-traditional risk groups.² Early use of steroids in moderate to severe PCP improves oxygenation and reduces mortality.³ CMV co-infection in immunocompromised patients further worsens prognosis and complicates management.⁴
Unique Aspects of Case: The patient’s HIV status was missed due to the absence of recent sexual history. A remote encounter with her ex-husband — years after their divorce led to silent transmission. Her presentation mimicked resistant bacterial pneumonia until PCP and CMV were confirmed. Only upon critical deterioration and exhaustive workup was the diagnosis of AIDS uncovered. The case is also notable for rapid decompensation despite appropriate antimicrobial and antiretroviral therapy, with features of IRIS and CMV viremia.
Recommendations/Conclusions: Clinicians must maintain high suspicion for HIV in patients with atypical pneumonia, even in low-risk or older populations. Broad infectious workups, including fungal and viral pathogens, are critical in severe, non-resolving pneumonia. Early initiation of HAART and corticosteroids is vital in PCP.
