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Acute respiratory failure with an unexpected etiology in an elderly patient

Published:August 18, 2017DOI:https://doi.org/10.1016/j.ejim.2017.08.015

      1. Indication

      An 80-year-old woman with no history of smoking developed a productive cough 8 days prior to admission. Neither levofloxacin nor sulbactam/ampicillin, prescribed at the previous hospital, were effective. She was transferred to our hospital on the 8th day because she developed dyspnea and hypoxemia. On admission, she was alert and oriented. Her blood pressure was 98/57 mmHg, heart rate 100 beats/min, body temperature 37.0 °C, respiratory rate 42/min, and oxygen saturation 98% with 6 L/min of oxygen via a facial mask. She had neither jugular vein distention nor edema. Heart and respiratory sounds were normal. Laboratory findings showed a white blood cell count of 5.6 × 103/μL with neutrophils of 79.5%, C-reactive protein 9.9 mg/dL, and N-terminal pro-brain natriuretic peptide 243.7 pg/mL. Chest computed tomography (Fig. 1) revealed consolidation and ground-glass opacity around the central bronchovascular bundle of the entire lung field, and cysts in the upper lung field. Cultures of blood and sputum were sterile. A medical interview revealed a previous male partner with whom she had engaged in sexual intercourse who had died several months earlier.
      Fig. 1
      Fig. 1Chest computed tomography.Chest computed tomography revealed consolidation and ground-glass opacity around the central bronchovascular bundle. Ground-glass opacity involves intra-lobular reticulation and hyperplasia of the septa. Cysts on the superior lobe of lung and bronchial expansion causing traction are evident.

      2. Diagnosis

      Chest imaging and laboratory tests showing elevated blood beta-D glucan 130.5 pg/mL, positive for human immunodeficiency virus (HIV) antigen antibody, and CD4+ cell count 23/μL supported the diagnosis of pneumocystis pneumonia with acquired immunodeficiency syndrome (AIDS). After beginning methylprednisolone (80 mg/day) and trimethoprim-sulfamethoxazole (720/3,600 mg/day), her respiratory condition and general status improved. On the 51st hospital day, she was transferred to another hospital for further recuperation.
      Patients newly diagnosed with HIV/AIDS are generally in the 25–44 age range, the range in which people are typically most sexually active [
      • Qaseem Amir
      • Snow Vincenza
      • Shekelle Paul
      • Hopkins Jr., Robert
      • Owens Douglas K.
      Screening for HIV in health care settings: a guidance statement from the American college of physicians and HIV medicine association.
      ]. The United States Preventive Services Task Force recommends HIV screening of high risk patients aged between 15 and 65 [
      • Moyer Virginia A.
      Screening for HIV: U.S. preventive services task force recommendation statement.
      ]. Older people are usually considered to have decreased sexual activity. However, a large-scale study reported that 16.7% of women aged between 75 and 85 had sexual intercourse at least once per year and 54.1% had sexual intercourse two or three times per month [
      • Lindau Stacy Tessler
      • Philip Schumm L.
      • Laumann Edward O.
      • Levinson Wendy
      • O'Muircheartaigh Colm A.
      • Waite Linda J.
      A study of sexuality and health among older adults in the United States.
      ]. It is suggested that medical professionals inquire about the sexual activity of a patient irrespective of the person's age when taking their medical history. The possibility of an HIV infection should not be dismissed based only on a person's advanced age.

      Conflicts of interest

      None.

      References

        • Qaseem Amir
        • Snow Vincenza
        • Shekelle Paul
        • Hopkins Jr., Robert
        • Owens Douglas K.
        Screening for HIV in health care settings: a guidance statement from the American college of physicians and HIV medicine association.
        Ann Intern Med. 2009; 150: 125-131
        • Moyer Virginia A.
        Screening for HIV: U.S. preventive services task force recommendation statement.
        Ann Intern Med. 2013; 159: 51-60
        • Lindau Stacy Tessler
        • Philip Schumm L.
        • Laumann Edward O.
        • Levinson Wendy
        • O'Muircheartaigh Colm A.
        • Waite Linda J.
        A study of sexuality and health among older adults in the United States.
        N. Engl. J. Med. 2007; 357: 762-774