Acute Shortness Of Breath

Hx: A young male in his late 20’s presents with shortness of breath. He denies any past medical history and notes that symptoms only began a few days ago. He began with a cough that seemed to get severely worse a day or two ago. Despite his denial of other symptoms or history, he seems to have some difficulty recalling timelines and is unconcerned with his current symptoms.

PMHx: none

SocHx: Denies alcohol, tobacco, or drug use. Is a student but is currently homeless?

Meds: None

Exam:

• Vitals: BP 110/90, HR 100, RR 35, O2 Sat 80’s on room air
• General: skinny male in moderate distress due to shortness of breath
• HEENT: normal
• Resp: coarse breath sounds bilaterally, diminished breath sounds bilaterally, no wheezes, in moderate respiratory distress.
• Cardiovascular: tachycardia, regular, pulses equal all extremities
• Abdomen: soft, non-tender
• Extremities: normal pulses, warm
• Neuro/Psych: alert, awake, flat affect, slow to answer questions, short answers to questions.

ED course:

After being placed on a cardiac monitor, a chest X-ray is obtained demonstrating the process below:

The patient is subsequently taken to CT to further define the process showing the following:

During the ED course, the patient’s mother is reached who relates that the patient has a recent history of worsening memory and mental status over the past few months. She denies any known past medical history but admits that the patient has been difficult to reach and lost to follow up because of his worsening mental status.

Laboratory evaluation shows anemia, leukopenia, and thrombocytopenia. There is also a low albumin, but normal renal function.

The patient is admitted but has increasing respiratory distress requiring tube thoracostomy on the left.  Broad spectrum antibiotic therapy for pneumonia is initiated as further testing is ordered.

Hospital Course :

On hospital day #2 his respiratory status declines again and the following film is obtained:

The patient subsequently has a second tube thoracostomy, this time on the right.

HIV testing returns positive with a critically low CD4 count and the diagnosis is made.

Diagnosis:

• Pneumocytis jirovecii pneumonia with pneumothorax and pneumomediastinum
• HIV dementia

Discussion:

As HIV testing and treatment has become more common, complications of severe untreated HIV infection (AIDS) are seen with decreasing frequency. This case demonstrates at least two of the complications of untreated HIV infection.

Pneumocystis pneumonia is a severe and a life threatening infection caused by the fungus pneumocystis jirovecii. It was formerly called pneumocystis carinii (PCP) and classified as a protozoa. Infection is a complication of the immunosuppression caused by HIV infection, and it is considered an AIDS defining illness. As CD4 counts drop, the body’s ability to fight infectious organisms declines resulting in this organism causing severe lung injury. Infected alveoli and membranes break down leaving patients with current or past PCP infection at increased risk of developing a pneumothorax. Studies have shown that 1-5% of patients with PCP can experience a pneumothorax. This can occur as a result of positive pressure ventilation or spontaneously. In general, outcome is better if the pneumothorax develops spontaneously, however, the development of a pneumothorax increases mortality significantly (up to 30%). In this case, the patient’s late presentation caused him to have significant subcutaneous, intra-thoracic, and mediastinal air. Left untreated, the trapped air continues to build resulting in death. Decompression with tube thoracostomy and treatment of the PCP infection in addition to initiation of HAART therapy gives the patient the best chance at survival. Due to the severe lung injury in PCP pneumonia (cystic disease and significant alveolar injury), persistent air leaks are common and patients frequently require consultation with thoracic surgery and pleurodesis.  Pneumothorax can also occur due to bacterial pneumonia but that is more common when CD4 counts are > 200.

Dementia in AIDS patients was a common finding effecting between 30-60% of HIV infected patients with CD4 counts < 200. However, highly active anti-retroviral therapy (HAART) has decreased the frequency to less than 20%. The etiology of AIDS dementia is not believed to be due to any opportunistic infection but instead a direct effect of the virus. It is not known if the virus directly injures neurons or causes an inflammatory response that results in the damage. Regardless, HAART therapy has been shown to reduce the occurrence of the dementia and in some cases to improve the symptoms after the diagnosis is made. Patients typically present with problems focusing, delayed mental processing, difficulty with learning new tasks, behavioral changes, memory problems, confusion and difficulty with word finding. In severe cases, speech, balance, and vision problems can occur in conjunction with weakness and seizures. Apathy is also common, which explains the patient’s flat affect and unconcerned state despite the severity of his symptoms in this case. In the absence of treatment, symptoms progress to a vegetative state. The evaluation for HIV/AIDS dementia should include imaging (CT and/or MRI) to exclude stroke and lumbar puncture to exclude other infectious causes.

Unfortunately, this case highlights the likelihood of multiple concomitant complications of HIV when CD4 counts fall below 200 and patients are classified with AIDS.