(858) Primary HIV Presenting as Acute Hypoxic Respiratory Failure and ARDS in an Infant

Introduction: Rates of primary HIV infection in children are almost universally from vertical transmission and continue to decline in the United States as routine screening and the availability of pre-exposure prophylaxis continue to improve. Typically, pregnant mothers are screened at their first prenatal visit, with repeat testing during the third trimester recommended in areas with high incidence, or for women at high risk of contracting HIV. We present a case of a previously healthy infant who developed acute respiratory distress syndrome (ARDS) secondary to congenitally acquired HIV infection despite her mother testing negative during pregnancy.

Description: A previously healthy 3-month-old presented to an outside hospital with acute hypoxic respiratory failure in the setting of a two-week history of cough. Her chest X-ray revealed bilateral upper lobe infiltrates. She was initiated on IV antibiotics but continued to have worsening hypoxia prompting transfer to our PICU. A chest CT showed a left-sided pneumothorax requiring chest tube placement. She was intubated for refractory hypoxia despite non-invasive ventilation. She underwent bronchoscopy with signs of alveolar hemorrhage, prompting a vasculitis panel, viral testing, and non-accidental trauma screening. The patient was found to be HIV positive and started on antiretroviral therapy, steroids, and prophylactic Bactrim. Further testing was sent for opportunistic infections including Pneumocystis jirovecii and Mycobacterium. She remained intubated for ten days, after which she was extubated and gradually weaned off respiratory support. She was discharged home on antiretroviral therapy with close outpatient follow-up.

Discussion: We present a case of acute hypoxic respiratory failure, pediatric ARDS, and alveolar hemorrhage secondary to primary HIV, which is a rare first presentation of primary infection not otherwise well documented in the literature. Ultimately, it was the presence of diffuse alveolar hemorrhage that prompted HIV testing. This case demonstrates the need to maintain a wide differential for pediatric ARDS in this age group, despite negative prenatal testing.