Clinical Report: A Persistent Cough and an Unexplained Diagnosis

Overview

An 80-year-old woman was diagnosed with advanced HIV-1 infection complicated by Pneumocystis jirovecii pneumonia and cryptococcal pneumonia after presenting with cough and hypoxemia. The case highlights the importance of HIV screening in older adults, especially those with unexplained respiratory symptoms.

Background

HIV infection remains a significant public health concern, particularly among older adults who may present with advanced disease. Opportunistic infections like Pneumocystis jirovecii pneumonia are common in individuals with advanced HIV, underscoring the need for timely diagnosis and treatment. This case illustrates the complexities of diagnosing respiratory illnesses in the context of undiagnosed HIV infection.

Data Highlights

The patient had an HIV-1 viral load of 223,000 copies/mL and a CD4 count of 33 cells/µL. Initial tests for common respiratory pathogens were negative, and bronchoalveolar lavage confirmed P. jirovecii infection.

Key Findings

• The patient presented with cough, weight loss, and hypoxemia, with an oxygen saturation of 83%.
• Chest CT revealed diffuse ground-glass opacities in both lungs.
• HIV-1 antigen-antibody testing was reactive, confirming advanced HIV infection.
• Bronchoalveolar lavage confirmed P. jirovecii infection, and fungal cultures grew Cryptococcus neoformans.
• High-dose trimethoprim-sulfamethoxazole and adjunctive glucocorticoids were administered, leading to a favorable response.
• Older adults represent a significant proportion of individuals living with HIV, often diagnosed at advanced stages.

Clinical Implications

This case emphasizes the necessity of HIV risk assessment and screening in older patients presenting with respiratory symptoms. Clinicians should consider opportunistic infections in patients with advanced HIV, particularly when common pathogens are ruled out.

Conclusion

The diagnosis of advanced HIV-1 infection with concurrent opportunistic infections highlights the critical need for awareness and screening in older adults. Timely intervention can lead to significant clinical improvement.

References

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3. NIH, Cryptococcosis: Adult and Adolescent OIs, 2025 -- Management Guidelines
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13. Cryptococcosis: Adult and Adolescent OIs | NIH