Abstract Introduction While Streptococcus pneumoniae bacteremia is a recognized complication of advanced HIV, simultaneous bacterial, opportunistic, and cardiac involvement at the time of diagnosis is rare. We present a 36-year-old man with newly diagnosed AIDS who developed pneumococcal sepsis, Pneumocystis jirovecii pneumonia, candidiasis, and echocardiographic findings concerning for endocarditis with pericardial effusion - illustrating the profound multisystem impact of severe immunosuppression. Case Description A 36-year-old male with intravenous heroin and methamphetamine use presented with two weeks of dyspnea, productive cough, diarrhea, and chest pain. He denied a history of HIV or STIs. On admission, hemoglobin was 5.1 g/dL, sodium 130 mmol/L, lactate 3.3 mmol/L, and procalcitonin 8.97 ng/mL. HIV-1/2 antibody was positive. Imaging revealed diffuse bilateral infiltrates and small pleural effusions. Blood cultures grew Streptococcus pneumoniae. Within 24 hours, he developed septic shock and acute hypoxic respiratory failure requiring intubation, vasopressor support, and broad antimicrobial therapy (ceftriaxone, linezolid, Bactrim with prednisone, azithromycin, and fluconazole). Bronchoscopy confirmed Pneumocystis jirovecii by PCR; β-D-glucan and CMV PCR were positive. ART with dolutegravir and tenofovir/emtricitabine was initiated. Transthoracic echocardiography demonstrated an ejection fraction of 45-50%, severe mitral regurgitation, circumferential pericardial effusion without tamponade, and mobile echodensities on the aortic and tricuspid valves concerning for endocarditis. The patient improved, was extubated after six days, and psychiatry managed transient delirium. He later developed atrial fibrillation with rapid ventricular response treated with amiodarone. Despite counseling on adherence and prognosis, he left the hospital against medical advice on day 23. Discussion This case represents an uncommon, multifactorial AIDS presentation involving concurrent bacterial sepsis, opportunistic pneumonia, fungal infection, and cardiac structural disease. Profound immune depletion (CD4 = 5) predisposed to invasive pneumococcal and opportunistic infections, while echocardiographic findings suggested polymicrobial or pneumococcal endocarditis with pericardial effusion. This overlap underscores how new AIDS diagnoses may manifest with overlapping critical illnesses rather than a single opportunistic process. Early recognition, antiretroviral initiation, and multidisciplinary coordination remain critical to improving survival in such presentations. This abstract is funded by: None
Crisler et al. (Fri,) studied this question.