Hx:
A young male in his late 20’s presents with shortness of breath. He denies any past medical history and notes that symptoms only began a few days ago. He began with a cough that seemed to get severely worse a day or two ago. Despite his denial of other symptoms or history, he seems to have some difficulty recalling timelines and is unconcerned with his current symptoms.
PMHx:
none
SocHx:
Denies alcohol, tobacco, or drug use. Is a student but is currently homeless?
Meds:
None
Exam:
- Vitals: BP 110/90, HR 100, RR 35, O2 Sat 80’s on room air
- General: skinny male in moderate distress due to shortness of breath
- HEENT: normal
- Resp: coarse breath sounds bilaterally, diminished breath sounds bilaterally, no wheezes, in moderate respiratory distress.
- Cardiovascular: tachycardia, regular, pulses equal all extremities
- Abdomen: soft, non-tender
- Extremities: normal pulses, warm
- Neuro/Psych: alert, awake, flat affect, slow to answer questions, short answers to questions.
ED course:
After being placed on a cardiac monitor, a chest X-ray is obtained demonstrating the process below:
Image courtesy of Sam Ashoo, MD
The patient is subsequently taken to CT to further define the process showing the following:
Image courtesy of Sam Ashoo, MD
During the ED course, the patient’s mother is reached who relates that the patient has a recent history of worsening memory and mental status over the past few months. She denies any known past medical history but admits that the patient has been difficult to reach and lost to follow up because of his worsening mental status.
Laboratory evaluation shows anemia, leukopenia, and thrombocytopenia. There is also a low albumin, but normal renal function.
The patient is admitted but has increasing respiratory distress requiring tube thoracostomy on the left. Broad spectrum antibiotic therapy for pneumonia is initiated as further testing is ordered.
Hospital Course :
On hospital day #2 his respiratory status declines again and the following film is obtained:
The patient subsequently has a second tube thoracostomy, this time on the right.
HIV testing returns positive with a critically low CD4 count and the diagnosis is made.
Diagnosis:
- Pneumocytis jirovecii pneumonia with pneumothorax and pneumomediastinum
- HIV-associated neurocognitive disorder
Discussion:
As HIV testing and treatment has become more common, complications of severe untreated HIV infection (AIDS) are seen with decreasing frequency. This case demonstrates at least two of the complications of untreated HIV infection.
Pneumocystis pneumonia is a severe and a life threatening infection caused by the fungus pneumocystis jirovecii. It was formerly named pneumocystis carinii (PCP) and classified as a protozoa. Infection is a complication of the immunosuppression caused by HIV, and it is considered an AIDS defining illness. As CD4 counts drop, the body’s ability to fight infectious organisms declines resulting in this organism causing severe lung injury. Infected alveoli and membranes break down leaving patients with current or past pneumocystis infection at increased risk of developing a pneumothorax. Studies have shown that up to 9% of patients with pneumocystis pneumonia can experience a pneumothorax 1. This can occur as a result of positive pressure ventilation or spontaneously. In general, outcome is better if the pneumothorax develops spontaneously, however, the development of a pneumothorax increases pneumocystis pneumonia mortality significantly.
In this case, the patient’s late presentation caused him to have significant subcutaneous, intra-thoracic, and mediastinal air. Left untreated, the trapped air continues to build resulting in death. Decompression with tube thoracostomy and treatment of the pneumocystis infection in addition to initiation of highly active anti-retroviral therapy (HAART) gives the patient the best chance at survival. Due to the severe lung injury in pneumocystis pneumonia, including cystic disease and significant alveolar injury, persistent air leaks are common and patients frequently require consultation with thoracic surgery and pleurodesis. Pneumothorax can also occur due to bacterial pneumonia but that is more common when CD4 counts are > 200.
HIV-associated neurocognitive disorder (HAND) can rage from mild to severe. The most severe type is named HIV assocaited dementa. It was a common finding effecting between 30-60% of HIV infected patients with CD4 counts < 200. However, highly active anti-retroviral therapy (HAART) has decreased the frequency to less than 20% 2,3. The etiology of HAND is not believed to be due to an opportunistic infection but instead a direct effect of the virus. It is not known if the virus itself injures neurons or causes an inflammatory response that results in the damage. Regardless, HAART therapy has been shown to reduce the occurrence of dementia and in some cases to improve the symptoms after the diagnosis is made. Patients typically present with problems focusing, delayed mental processing, difficulty with learning new tasks, behavioral changes, memory problems, confusion and difficulty with word finding. In severe cases, speech, balance, and vision problems can occur in conjunction with weakness and seizures.
Apathy is also common, which explains the patient’s flat affect and unconcerned state despite the severity of his symptoms in this case. In the absence of treatment, symptoms progress to a vegetative state. The evaluation for HAND should include imaging (CT and/or MRI) to exclude stroke and lumbar puncture to exclude other infectious causes.
Unfortunately, this case highlights the likelihood of multiple concomitant complications of HIV when CD4 counts fall below 200 and patients are classified with AIDS.
For Further Reading:
Managing the HIV-Infected Adult Patient in the Emergency Department (Infectious Disease CME, Pharmacology CME and HIV CME)ED management of HIV patients now includes management of age-related concerns, side effects of antiretroviral therapies, and PEP and PrEP regimens.
An Evidence Based Thoracic Imaging Curriculum for Emergency MedicineThis issue of Emergency Medicine Practice provides an overview of thoracic imaging modalities and guidance on the indications for each test in emergency
References:
- McClellan MD, Miller SB, Parsons PE, Cohn DL. Pneumothorax with Pneumocystis carinii pneumonia in AIDS. Incidence and clinical characteristics. Chest. 1991 Nov;100(5):1224-8. doi: 10.1378/chest.100.5.1224. PMID: 1935275.
- Singer EJ, Thames AD. Neurobehavioral Manifestations of Human Immunodeficiency Virus/AIDS: Diagnosis and Treatment. Neurol Clin. 2016 Feb;34(1):33-53. doi: 10.1016/j.ncl.2015.08.003. PMID: 26613994; PMCID: PMC4663681.
- Living With HIV Associated Neurocognitive Disorder (HAND), Alzheimer’s Australia, Alzhiemier’s Australia Vic, 2014
Last Updated on January 24, 2023
Sam Ashoo, MD, FACEP, is board certified in emergency medicine and clinical informatics. He serves as EB Medicine’s editor-in-chief of interactive clinical pathways and FOAMEd blog, and host of EB Medicine’s EMplify podcast. Follow him below for more…
What about pulmonary tb ? Resulting into a chronic lung disease , with those cavitation
Seen on the X-ray , the disease can also cause formation of a Bleb or Bullae which can rupture and produce the same symptoms as seen in this patient
Just my though
Yes absolutely. The differential for bullous lung disease does include pulmonary TB. Tuberculosis can also cause infection in someone who already has bullae, further complicating matters. It was not the diagnosis for this patient, but important to consider regardless.