Abstract Background Pneumocystis jirovecii pneumonia (PJP) remains a life-threatening opportunistic infection in patients with advanced HIV. On imaging, bilateral ground-glass opacities with perihilar and upper lobe predominance are classic, and acute disease can be complicated by cyst formation and pneumothoraces. These cystic lesions typically regress with treatment, and persistent bullous disease is rarely reported in HIV-positive patients. We present a unique case of severe PJP complicated by multiple opportunistic infections, ARDS, and immune reconstitution inflammatory syndrome (IRIS), leading to prolonged bullous changes and structural lung disease. Case Presentation A 47-year-old male with untreated HIV (CD4 34, viral load 1,000,000), pernicious anemia, and ANCA vasculitis presented with altered mental status and hypoxemic respiratory failure. Chest CT showed a right pneumothorax, diffuse ground-glass opacities, and cystic changes concerning for PJP. Bronchoalveolar lavage confirmed PJP with concurrent CMV and HSV infection, and (1,3)-beta-D-glucan was markedly elevated. The patient developed ARDS requiring neuromuscular blockade, inhaled nitric oxide, and prolonged mechanical ventilation. ART was initiated on hospital day 17, complicated by IRIS with worsening pulmonary inflammation. His course was further marked by ventilator-associated pneumonia due to carbapenem-resistant Pseudomonas aeruginosa. Serial chest imaging by hospital day 57 demonstrated extensive bilateral pneumatoceles and persistent bullous changes, with 1-month follow-up images showing mild improvement, but continued persistence of changes. Despite eventual stabilization on a tracheostomy collar, he remained at high risk for recurrent infections and long-term respiratory impairment. Discussion This case underscores several key teaching points. First, while cysts and pneumothoraces are recognized complications of acute PJP, persistent bullous lung disease is distinctly uncommon, particularly in HIV patients who usually demonstrate radiographic resolution. Second, the interplay of untreated HIV with profound immunosuppression, opportunistic viral co-infections, delayed ART initiation, IRIS, and ventilator-induced lung injury likely contributed to progressive alveolar destruction. Persistent bullae increase the risk of pneumothorax, recurrent infections, and impaired pulmonary function, representing a significant long-term sequela even after microbiologic clearance. Conclusion Severe PJP in ART-naïve HIV patients can result in complex, multifactorial pulmonary injury with lasting structural consequences. This case highlights the importance of early diagnosis and timely ART initiation to mitigate tissue injury and raises awareness that persistent bullous disease, though rare, may complicate recovery and impact long-term outcomes. This abstract is funded by: None
Reitnauer et al. (Fri,) studied this question.