A 47-year-old man from Nigeria with no past medical history presented to the hospital with complaints of chills, weight loss, productive cough, and shortness of breath over the course of one month.  He was previously treated as an outpatient for an early community acquired pneumonia at the onset of his symptoms; however, his clinical status continued to deteriorate. 

Upon arrival to the emergency department, he was febrile and hypoxic with a leukocytosis; therefore sepsis protocol was initiated.  He was started on IV fluids and broad spectrum antibiotics, defervesced with antipyretics, placed on nasal cannula, and underwent new imaging; that of which was concerning for a multifocal pneumonia.  The etiology of his symptoms was further investigated and he was found to be HIV positive on admission with a viral load of 122,000 and a CD4 count of 238 cells per μL.

A CT scan of the lungs revealed diffuse ground glass opacities. The patient was subsequently started on HAART therapy, as well as Bactrim and methylprednisolone for a suspected pneumocystis jirovecii pneumonia (PJP).  He underwent bronchoscopy with bronchoalveolar lavage (BAL) to rule out PJP.  Post-operatively, the patient became tachypnic, desaturated to 80% on 5L nasal cannula, and was upgraded to high-flow oxygen therapy.  A repeat chest x-ray was obtained, which confirmed a worsening multifocal pneumonia with advancement to acute respiratory distress syndrome.

The case report draws attention to the rapid progression of PJP pneumonia to ARDS and emphasizes the importance of early diagnosis and treatment.

Keywords: Acquired immunodeficiency syndrome, AIDS, Acute respiratory distress syndrome, ARDS, Human Immunodeficiency Virus, HIV, Pneumocystis Pneumonia