(106) The Diagnostic Odyssey: Pulmonary Embolism Leading to Discovery of PJP and AIDS

Introduction: Efforts to eliminate HIV transmission are ongoing, with widespread availability of testing opportunities. However, opportunities for HIV testing and diagnosis are often missed. Pneumocystis Jirovecii pneumonia (PJP) can present as an initial opportunistic infection in patients admitted to ICU.

Description: A 36-year-old healthy female with recent hysteroscopic myomectomy for uterine bleeding two weeks ago presented to the Emergency Room with complaints of persistent shortness of breath, dyspnea on exertion, and palpitations persisting for two weeks post recent surgery. CT Chest with Pulmonary Embolism (PE) protocol revealed a right lower lobe PE, diffuse pulmonary edema, and ground glass opacities. She was transferred to the Intensive Care Unit (ICU) due to tachycardia and acute blood loss anemia. She was started on Intravenous heparin but was persistently febrile with refractory tachycardia. Workup was sent for upper and lower respiratory pathogen panels, and was empirically started on Levofloxacin. She had minimal improvement, and an HIV test was sent that returned positive. A broader infectious workup was repeated, including a sputum test for PJP, confirming the diagnosis. Her CD4 count was 20 and Viral Load was 109,000. PJP treatment was initiated, with good clinical response to treatment and patient was discharged from ICU.

Discussion: Acute or early HIV infection diagnosis is infrequently made in clinical practice. In a case series from Seattle, the diagnosis of HIV infection was considered in only 26 percent of patients with acute retroviral syndrome who sought care from primary care clinicians, emergency departments, and walk-in clinics. We maintained a high index of suspicion for an immunocompromised status and hence directed HIV testing while the patient was in the ICU. The diagnosis of acute PJP as an AIDS-defining illness emphasizes the need to improve compliance with CDC and USPSTF guidelines. The CDC recommends that everyone aged 13 to 64 get tested for HIV at least once as part of routine health care, a recommendation also supported by the USPSTF. This case highlights a missed opportunity and underscores gaps in routine HIV screening and advocates for healthcare systems to implement protocols for recognizing and timely screening for HIV in adults.