What does this research mean for the field?

In advanced HIV patients with acute hypoxemic respiratory failure, concurrent pulmonary infections can drive the clinical picture, beta-D-glucan levels do not reliably track clinical response, and rapid-start ART is feasible even during mechanical ventilation. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

This case aims to illustrate the occurrence of concurrent infections in a patient with newly diagnosed AIDS and their implications for treatment.

May 20, 2026

C48-30 Two Fires in One Lung: Concurrent Pneumocystis Jirovecii Pneumonia and Invasive Pneumococcal Disease Presenting With Acute Hypoxemic Respiratory Failure in New Aids

Key Points

This case aims to illustrate the occurrence of concurrent infections in a patient with newly diagnosed AIDS and their implications for treatment.
Case report of a 36-year-old man with advanced HIV presenting with dual pulmonary infections.
Treatment involved high-dose trimethoprim-sulfamethoxazole, ceftriaxone, and rapid-start ART initiated in the ICU.
Diagnosis utilized bronchoscopy and testing for beta-D-glucan and PCR.
Patient intubated within 24 hours due to respiratory failure and required significant oxygen support.
BDG elevated but not a reliable tracker for clinical response; patient improved after initiating ART.
Patient extubated by hospital day 8 with improved oxygenation and radiographic results.

Abstract

Abstract Introduction Dual pulmonary infections remain an underrecognized driver of acute hypoxemic respiratory failure in advanced HIV. This case highlights concurrent Pneumocystis jirovecii pneumonia (PJP) and invasive pneumococcal disease in a newly diagnosed patient with AIDS, the limited value of beta-Dglucan (BDG) trending, and the feasibility of rapid-start antiretroviral therapy (ART) in the ICU. Case A 36-year-old man with intravenous drug use presented with two weeks of dyspnea, productive cough, diarrhea, and chest pain. On arrival: Hgb 5.1 g/dL, CRP 17.2 mg/dL, diffuse bilateral infiltrates; he progressed from nasal cannula to BiPAP and required intubation within 24 hours. Blood cultures grew Streptococcus pneumoniae (2/2). Bronchoscopy yielded thick secretions; PJP PCR from lower respiratory specimens was positive. BDG was elevated (362 pg/mL) and rose to 405 pg/mL while the patient clinically improved. He received high-dose trimethoprim-sulfamethoxazole plus adjunctive corticosteroids for PJP and ceftriaxone for pneumococcal bacteremia; azithromycin was discontinued. Rapid-start ART (dolutegravir + tenofovir disoproxil fumarate/emtricitabine) was initiated in the ICU. He was extubated by hospital day 8 with radiographic and oxygenation improvement. CMV PCR was detectable without end-organ disease; ganciclovir was not started. Given immediate ART initiation, primary MAC prophylaxis was not given. He completed fluconazole for thrush/esophagitis and continued ceftriaxone with a planned total of four weeks for probable endocarditis; he later left against medical advice. All data were de-identified; patients provided consent for abstract submission. Discussion/Novelty This case demonstrates that in advanced HIV, a single clinical picture may be driven by two pathogens requiring simultaneous therapy. BDG supported the PJP diagnosis but did not track clinical response, cautioning against treatment decisions based on BDG kinetics alone. Initiating integrase-based ART during mechanical ventilation was operationally feasible and not associated with clinical deterioration or Immune Reconsititution Inflammatory Syndrome. Conclusion In AIDS-associated respiratory failure, maintain vigilance for dual-etiology infection. Use BDG primarily as a diagnostic adjunct, not as a response biomarker, and consider rapid-start ART even in the ICU when drug interactions and absorption are manageable. This abstract is funded by: None

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