Rhodococcus equi infections in HIV late presenters: A case series and therapeutic challenges

Introduction. Rhodococcus equi is a rare but clinically relevant opportunistic pathogen, primarily affecting individuals with compromised cellular immunity. In people living with HIV/AIDS, it typically manifests as severe pulmonary disease. The objective of this case series is to describe the clinical features, management, and outcomes of R. equi infection in three men with advanced HIV/AIDS. Outlines of cases. We retrospectively analyzed three cases of R. equi infection treated between 2004 and 2011 at the Clinic for Infectious and Tropical Diseases, University Clinical Center Serbia, in Belgrade. All patients were men with CD4 counts below 50 cells/mL at the time of presentation. Clinical symptoms included prolonged fever, productive cough, weight loss, and malaise. Pulmonary involvement was universal, with radiological findings of necrotizing pneumonia or cavitary lung abscess. One patient developed cerebritis as an extrapulmonary manifestation. R. equi was isolated from sputum in all three cases and from blood cultures in two cases. All patients required prolonged hospitalization and combination antibiotic therapy, including macrolides, carbapenems, rifampicin, and trimethoprim-sulfamethoxazole, with antiretroviral therapy introduction. Two patients achieved long-term clinical stability, while one had persistently low CD4 count and detectable viral load due to adherence issues. Conclusion. Rhodococcus equi in patients with advanced HIV/AIDS may cause severe pulmonary or disseminated disease. Early recognition, tailored antimicrobial regimens, and careful timing of ART initiation are critical to improve outcomes in this population.