Infection in an Immunocompromised Patient, the Perfect Costume in Which to Hide

Abstract

A 61-year-old male, recently diagnosed of HIV infection in AIDS stage after a Pneumocystis jirovecii pneumonia (PCP), reconsulted because of fever. Worsening of previous bilateral infiltrates on chest X-ray and inflammatory signs on blood test were observed. With the suspicion of PCP relapse, steroids were restarted, as well as empiric antibiotic and antifungal treatment.

A quantitative decrease of Pneumocystis cysts on bronchoalveolar lavage (BAL) was found, and Mycobacterium avium intracelulare was isolated in a sputum culture from the first admission. Therefore, specific treatment was started. Nevertheless, the patient developed a respiratory worsening that led him to ICU admission under invasive mechanical ventilation. Positive PCR test for cytomegalovirus in a new BAL and serum was detected, thus foscarnet was initiated. However, he remained feverish and sudden anisocoria and seizures appeared. Cranial CT scan showed multiple ischemic injuries, therefore with the endocarditis suspicion, transesophageal cardiac ultrasound was performed showing mitro-aortic vegetations. Antibiotic and antifungal treatment was initiated because of positive beta-d-glucan (BDG) assay, being both stopped after repeatedly negative blood cultures, with the final diagnosis of marantic endocarditis.