Title : Acquired immunodeficiency syndrome with multiple opportunistic coinfections: Tuberculosis, cytomegalovirus, Pneumocystis pneumonia, and malaria – report of a rare and challenging case
Abstract:
This case illustrates a rare and challenging clinical presentation of AIDS with multiple simultaneous opportunistic coinfections, including viral, bacterial, fungal, and parasitic etiologies. We report the case of a 30-year-old male patient admitted to the intensive care unit of a referral hospital for infectious diseases, with a recent diagnosis of HIV infection and severe immunosuppression (CD4 count: 4 cells/mm³). He presented with a prolonged clinical course including persistent fever, weight loss, diarrhea, dry cough, and genital lesions. He had been on antiretroviral therapy (Tenofovir, Lamivudine, and Dolutegravir) for 13 days. On physical examination, he was in fair general condition, pale, dehydrated, febrile, and exhibited ulcerated lesions on the glans penis, with purulent base and erythematous borders. Upon admission, due to the severe immunodeficiency, expanded infectious screening was requested. Results revealed: positive PCR for cytomegalovirus (4,426 copies/mL), positive urinary TB-LAM antigen, and PCR for Pneumocystis jirovecii in bronchoalveolar lavage (642,000 copies/mL). Culture of the lavage fluid isolated multidrug-resistant Pseudomonas aeruginosa, sensitive only to carbapenems. CT scans showed extensive pulmonary consolidations, cavitations, ground-glass opacities, pericardial effusion, and mediastinal and abdominal lymphadenopathy. During hospitalization, the patient persisted with daily afternoon fever, raising the suspicion of malaria based on epidemiological context. Thick blood smear tested positive for Plasmodium vivax, and treatment with chloroquine and primaquine was initiated. He showed progressive clinical improvement, was discharged from the ICU after nine days, and from the hospital after 21 days. It highlights the importance of broad diagnostic investigation in febrile immunosuppressed patients and the potential for recovery with appropriate multidisciplinary management.
