A Persistent Cough and an Unexplained Diagnosis
NEJM case details the diagnostic evaluation of an 80-year-old woman with weeks of respiratory symptoms, weight loss, and diffuse ground-glass opacities on chest CT.
By
Olivia Anderson
February 2, 2026
Clinical Scorecard: A Persistent Cough and an Unexplained Diagnosis
At a Glance
Category Detail
Condition Advanced HIV-1 infection with Pneumocystis jirovecii pneumonia and cryptococcal pneumonia Key Mechanisms Opportunistic infections due to immunosuppression from advanced HIV infection Target Population Older adults, particularly those with undiagnosed HIV infection Care Setting Hospitalized patients with respiratory symptoms
Key Highlights
Patient presented with cough, weight loss, and hypoxemia Chest CT revealed diffuse ground-glass opacities HIV testing confirmed advanced HIV-1 infection Bronchoalveolar lavage confirmed P. jirovecii infection Treatment included high-dose trimethoprim-sulfamethoxazole and fluconazole Guideline-Based Recommendations
Diagnosis
Consider HIV testing in older adults with respiratory symptoms and weight loss Use bronchoalveolar lavage for confirmation of P. jirovecii pneumonia Management
Initiate high-dose trimethoprim-sulfamethoxazole for P. jirovecii pneumonia Administer fluconazole for cryptococcal pneumonia Start antiretroviral therapy after excluding CNS disease Monitoring & Follow-up
Monitor HIV viral load and CD4 cell count Assess response to treatment for respiratory symptoms Risks
Older adults are more likely to present with advanced HIV disease Cryptococcal antigen tests may be negative in isolated pulmonary infections Patient & Prescribing Data
Older adults with advanced HIV-1 infection
High-dose trimethoprim-sulfamethoxazole and adjunctive glucocorticoids are effective for P. jirovecii pneumonia
Clinical Best Practices
Conduct HIV risk assessment and screening in older adults Recognize the importance of timely diagnosis and treatment of opportunistic infections References
