Department of Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham S60 2UD, UK.

Corresponding Author: Dr. Roseleen Sheehan, Department of Elderly Medicine, Rotherham General Hospital, Moorgate Road, Rotherham, S60 2UD, UK. Tel: (+44) 01709 427576; Fax: (+44) 01709 424419; E-mail: Roseleen.sheehan@nhs.net.

	ABSTRACT
	INTRODUCTION
	DISCUSSION
	KEY LEARNING POINTS
	CONFLICTS OF INTEREST
	REFERENCES

	ABSTRACT

A 36-year-old British born Asian man was admitted to hospital with a dry cough, fever of one-week duration and a two-day history of diarrhoea. He was eventually diagnosed with pneumocystis jirovecii pneumonia secondary to human immunodeficiency virus infection. This case was challenging diagnostically due to the lack of a complete history initially and full history not being available until later in the admission. A normal chest x-ray also complicated matters. Around 90% of patients with pneumocystis jirovecii pneumonia have chest x-ray changes. Following diagnosis using high resolution computed tomography scan and bronchoalveolar lavage and subsequent treatment with co-trimoxazole and antiretroviral therapy, the patient recovered uneventfully.

	INTRODUCTION

   A 36-year-old British born Asian man was admitted to hospital with a dry cough, fever of one-week duration and a two-day history of diarrhoea. He received amoxicillin in the com-munity and he did not improve clinically. His past medical history included type 2 diabetes, psoriasis and acne. Medications included gliclazide, simvastatin, sitagliptin and lymecycline. On admission, he was pyrexial (38.6°C) and hypoxic (oxygen saturations 88% on air). Initial clinical examination was unremarkable. He was treated as lower respiratory tract infection with intravenous amoxicillin and clarithromycin. His first chest x-ray (Figure 1) was normal, and his blood results revealed haemoglobin (Hb) of 137 g/L, white cell count (WCC) of 6.6 × 109/L, platelets of 211 × 10⁹/L, a C-reactive protein (CRP) of 87 mg/L and normal urea and electrolytes (U&Es) and liver function tests (LFTs). Initially he improved with normalisation of oxygen saturations but remained mildly pyrexial at 37.6°C. On day 2, he spiked a tempera-ture of 39.6°C and his CRP rose to 200 mg/L. The medical team revisited the history for a second time and this revealed that he had contact with a relative with tuberculosis (TB) 6 months prior to In addition, he had lost around 6 Kg in weight and he had recurrent night sweats. Screening for atypical infections and TB were negative. Acid-fast bacilli (AFB) could not be isolated due to lack of sputum therefore; the medical team requested a high-resolution computarised tomography (CT) (Figure 2) scan to rule out TB. This demonstrated extensive diffuse ground glass changes. The history was revisited again and he admitted to one same sex encounter 5 months prior to admission and was consented for human immunodeficiency virus (HIV) testing. HIV was detected. He was then treated with a co-trimoxazole (trime-thoprim and sulphamethoxazole) for possible pneumocystis carinii pneumonia (PCP) infec-tion. He was seen by the infectious disease team and the history was revisited for a third time which revealed multiple (rather than a single) same sex partners over more than 6 months. The initial CD4 cell count was 11 cells/mm³ (normal range 500-1,500 cells/mm³) and viral load was 6.56 × 10⁵ copies/ml. Highly active anti-retroviral treatment consisting of Truvada (emtricitabine/tenofovir disoproxil fumarate) and Dolutegravir was started. PCP infection was confirmed on bronchoalveolar lavage. He continued to make good progress and was dis-charged after 17 days in hospital to complete a course of three weeks of co-trimoxazole and highly active antiretroviral therapy (HAART) long term. Outpatient clinic follow up showed much improvement in his viral load and CD4cell count (Table 1).

View larger version : [in a new window] Figure 1. Normal looking chest x-ray.

 

View larger version : [in a new window] Figure 2. Ground glass changes on high-resolution CT scan.

	DISCUSSION

   This case illustrates the presentation of a British born Asian man with signs and symptoms suggesting a lower respiratory tract infection. Appropriate management was instigated but despite this, he continued to deteriorate. He revealed that he had been in contact with a relative with TB, which led to investigation for this. This new working diagnosis was in fact a red herring. The history by the medical team was revisited once again and the relevant sexual history of this patient was revealed. This subsequently led to appropriate investigation and an accurate clinical diagnosis of advanced HIV and subsequent management. PCP is one of the most common opportunistic infections in immunocompromised individuals, which can lead to critical illness (1). It is a major cause of mortality and morbidity and is rarely seen in immune competent individuals. The diagnosis of this can be challenging because the patient may present with non-specific symptoms and concurrent infection. Infection is the most common cause of respiratory manifestations of HIV; however, neoplasms, lymphoma and interstitial pneumonias also play a significant role in the differential diagnosis (2). In patients who are profoundly immunocompromised, onset may be more dramatic and resemble other pulmonary infections as we have witnessed in this case (3). Other presentations of PCP include fever, tachypnea, chest pain, and one may show hypoxia at rest (4). The Health protection Agency in the UK estimates about 25% newly diagnosed HIV patients present with advanced HIV infection (5). Approximately 90% of chest radiographs in patients with PCP are abnormal and appearances are often non-specific (2). Between 10-15% of patients with PCP, have normal chest radiographs therefore highlighting that a normal chest X-ray does not rule out PCP. Standard CT imaging can show ground glass infiltrates but this has low sensitivity and specificity. High-resolution CT, however, has a sensitivity of 100% and a specificity of 89% (3). Features of a CT scan include a ground glass pattern which is a principle finding which predominantly involves the perihilar and mid zones (2). The organism that causes pneumocystis pneumonia (pneumocystis jirovecii) cannot be routinely cultured and is detected by staining of the cyst wall or trophozoite in sputum samples, usually with silver-based stains (4). If sputum is negative or one is unable to produce it and PCP is suspected, then bronchoscopy with bronchoalveolar lavage or transbronchial biopsy may detect the organism (4). In this case bronchoalveolar lavage was required to confirm the diagnosis. High dose co-trimoxazole (trimethoprim-sulfamethoxazole) is the drug of choice to treat PCP. Fever and a maculopapular rash is a common hypersensitive side effect and others include nausea, vomiting, skin reactions, neutropenia, thrombocytopenia and hepatitis. Co-trimoxazole should be avoided in those with severe hepatic or renal impairment (4). Alternatives to co-trimoxazole include atovaquone suspension and dapsone with trimethoprim (4). This case helps to emphasise the importance of revisiting the history when appropriate and not shying away from asking sensitive questions. The increased prevalence of TB in the Asian population should not distract us from thinking of other diagnoses. In addition, a normal chest x-ray does not always rule out serious infections. Unfortunately, HIV related stigma and discrimination prevent many people in the UK from accessing the services they need. Self-stigma and fear of a negative reaction can hinder efforts to address the HIV epidemic by continuing the perceived shame and silence surrounding the virus. Reporting this case helps support our requirement as medical professionals to support and encourage patients to be open and honest with us so as to aid a timely diagnosis and management of HIV and its complications.

	KEY LEARNING POINTS

1. History taking remains the most important aspect of diagnosis. If the history and clinical features do not match, always revisit.
2. Do not allow perceived embarrassment to prevent proper in-depth history taking.
3. A normal chest x-ray does not always rule out a respiratory tract infection. Ten percent of PCP cases present without x-ray changes.
4. Do not focus only on tuberculosis when an Asian patient presents with unusual respiratory symptoms.

	CONFLICTS OF INTEREST

   The authors declare that no conflicting interests exist.

	REFERENCES

1. Pneumocystis pneumonia remains a diagnostic challenge with PCR in acute settings. 46th Critical Care Congress of the Society of Critical Care Medicine, SCCM. 2016; 44 (Supplement 1): 520.
2. www.radiopedia.org. 2017. HIV/AIDS (pulmonary manifestations). [ONLINE] Available at: https://radiopaedia.org/articles/hivaids-pulmonary-manifestations-1. [Accessed 2nd May 2019]
3. Mark Thurston, Behrang Amini, et al. Pneumocystis pneumonia. Available: https://radiopaedia.org/articles/pneumocystis-pneumonia. 2017.
4. Public Health England. HIV: surveillance, data and management. [ONLINE] Available at: https://www.gov.uk/government/collections/hiv-surveillance-data-and-management. 2017.
5. https://emedicine.medscape.com/article/. Pneumocystis jiroveci Pneumonia (PJP) Overview of Pneumocystis jiroveci Pneumonia. [ONLINE] Available at: https://emedicine.medscape.com/article/225976-overview. 2017.
6. https://patient.info/health/medicines-for-hiv-and-aids [Accessed 21st April 2019].
7. http://www.gpnotebook.co.uk/simplepage.cfm?ID=577437731&linkID=76910&cook=no [Accessed 27th April 2019].
8. Public Health England. 2017. HIV: surveillance, data and management. [ONLINE] Available at: https://www.gov.uk/government/collections/hiv-surveillance-data-and-management. [Accessed 21st April 2019].

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