Newly diagnosed human immunodeficiency virus infection in an octogenarian with acute respiratory failure.

A previously healthy 83-year-old man presented to our emergency department with 3-day history of fever and dyspnea. Physical examination findings were as follows: oral temperature of 38.28C, pulse rate of 119 beats/min, respiratory rate of 32 breaths/ min, blood pressure of 108/67mmHg and diffuse crackles over bilateral lungs. Clinical laboratory findings were as follows: white blood cell count of 10.8 10/ml with 95% neutrophils, 3.2% lymphocytes, 1.7% monocytes, hemoglobin of 9.0 g/dl and platelets of 216 10/ml. Chest radiography revealed increased interstitial marking and groundglass opacities of both lungs (Figure 1A). The patient received oral endotracheal intubation on account of persistent dyspnea and hypoxiemia. On admission, a high-resolution computed tomography scan of the chest revealed diffuse groundglass opacities with thickening of interlobular septa of both lungs (Figure 2). Sputum bacterial cultures were negative. Other tests for pulmonary pathogens were performed, including a tuberculosis culture, acid-fast stain, polymerase chain reaction (PCR) for Pneumocystis jiroveci, cytomegalovirus (CMV) and HERPES simplex virus, and blood tests for CMV and Cryptococcus antigens. Three days later, PCR and antigens of CMV were positive in both sputum and blood. Immune status, including an human immunodeficiency virus (HIV) screening test was checked because CMV infection most commonly occurs in immunocompromised subjects. The HIV screening test and HIV western blot both revealed positive results. The CD4 lymphocyte count was 42/mm and HIV viral load was 5902000copies/ml. Ganciclovir was prescribed for 3 weeks and extubation was performed 6 weeks later. After 3-week ganciclovir treatment and 3-month highly active antiretroviral therapy, the patient underwent follow-up cell immune function tests and chest radiography examination. The CD4 lymphocyte count was 330/mm and HIV viral load was 769 copies/ml. Follow-up chest radiography revealed the resolution of increased interstitial marking and ground-glass opacities of both lungs (Figure 1B). The patient recovered well and was discharged in a stable condition.