ConcurrentPneumocystis jiroveciiand pulmonary histoplasmosis in an undiagnosed HIV patient

Abstract

Concurrent (PJ) and pulmonary histoplasmosis (PHP) are rare in a single HIV individual. We present a challenging case of concomitant PJ and PHP in a young HIV individual. A 44-year-old man presented to the emergency department with progressive pulmonary symptoms. He was hypoxic with bilateral pulmonary opacities on chest radiograph. CT of the chest showed a geographical pattern of ground-glass attenuation. He started receiving intravenous antibiotics in addition to oral Bactrim for suspected PJ. He also began receiving itraconazole, given suspected PHP with recent bat-droppings exposure. HIV test was positive, though history was negative; the CD4 count was 5 cells/mm Later, he developed respiratory failure without clinical improvement. First bronchoalveolar lavage (BAL) failed to confirm opportunistic pathogens. Repeat BAL revealed PJ but no Histoplasma. Histoplasma antigens were positive, confirming histoplasmosis. The patient died despite aggressive treatment with intravenous Bactrim and amphotericin B.

The conventional diagnosis challenge: Real-time PCR and nested PCR correlation with the scoring system for individuals at high-risk of Pneumocystis jirovecii pneumonia

“…The nested PCR targeting the P. jirovecii mitochondrial large subunit ribosomal RNA (mtLSUrRNA), was performed using in the first round the primers pAZ 102-H (5’- GTG TAC GTT GCA AAG TAC TC-3’) and pAZ 102-E (5’-GAT GGC TGT TTC CAA GCC CA-3’), and in the second reaction, the primers pAZ 102-X (5’-GTG AAA TAC AAA TCG GAC TAG G-3’) and pAZ 102-Y (5’-TCA CTT AAT ATT AAT TGG GGA GC-3’) 18 . A total volume of 50 µl was set for each reaction, containing 10 µl DNA, 10 µM Tris-HCI, 50 µM KCI, 2.5 mM MgCI 2 ,1.5 units of Taq DNA polymerase, 10 pM of each primer and 200 pM of dNTPs.…”

“…For example, increased serum lactate dehydrogenase is present in HIV-infected patients (14)(15)(16). Symptoms such as fever, cough, dyspnea, and, in severe cases, respiratory failure, are also manifestations of other infections, such as tuberculosis (17), histoplasmosis (18), cryptococcosis (19), communityacquired pneumonias (CAP) (20), and more recently, coronavirus disease 2019 (COVID-19) (21).…”

Pulmonary co-infection with Pneumocystis jirovecii and Histoplasma capsulatum in AIDS patients is not a rare event

“…The use of sensitive PCR assays for the routine diagnosis of both infections is relevant, specifically in HIV-infected patients living in, or who have lived in histoplasmosis endemic countries. Wheat et al (1985) USA (Indianapolis, Indiana) 2 Direct examination and/or culture a Baughman et al (1994) USA (Cincinnati, Ohio) 5 Direct examination and/or culture Huber et al (2008) France (Cayenne, French Guiana) 7 Direct examination and/or culture Velásquez et al (2010) Colombia (Medellin) 5 Direct examination and/or culture Le Gal et al (2013) France (Martinique) 1 Direct examination and/or culture Gago et al (2014) Spain (Barcelona) 1 PCR assays Almeida-Silva et al 2016Brazil (Rio de Janeiro) 1 PCR assays Caceres et al (2018) Colombia (Medellin) 3 Direct examination and/or culture or antigen detection b Wahab et al (2018) USA (Flint, Michigan) 1 Direct examination and/or culture or antigen detection b Carreto-Binaghi et al…”