Lethal Co-infection with Coccidiodes immitis/posadasii, MAI, and Pneumocystis jirovecii as a First Presentation of HIV

A 39-year old Mexican male with no past medical history presented to a teaching hospital in Dallas, Texas with dyspnea on exertion, cough, and fever. Clinical exam revealed crackles and wheezing in both lung bases. Laboratory studies revealed a positive rapid test for human immunodeficiency virus (HIV), but negative sputum cultures. His chest radiograph showed right paratracheal opacity and interstitial infiltrates. He developed worsening respiratory distress and required intubation, which was complicated by bilateral pneumothoraces and eventual death. He was diagnosed quickly with Pneumocystis jirovecii, but it took 13 days to grow Coccidioides immitis from his blood, and 22 days to grow Mycobacterium avium from his sputum, which was too late to alter his course. Given the frequency with which HIV patients acquire multiple opportunistic infections, rapid diagnostics are necessary in improving outcomes in these patients. In the era of highly effective antiretroviral therapy, fewer patients with human immunodeficiency virus are dying of opportunistic infections (OIs). However, patients who go undiagnosed until late in the disease course may present with multiple OI's at once, creating diagnostic and therapeutic challenges. This report describes a patient who presented with two classic OIs in addition to disseminated cocciciodomycosis. His case took nearly 2 weeks to diagnose and had a fatal outcome. Rapid diagnostics are important and can be life-saving to initiate effective therapy, and may have been useful in this case. Mechanisms of immune suppression and interaction between OIs are discussed.