COVID-19 and PCP co-infection in a severely immunocompromise
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A 25-year-old presented with profound hypoxemia despite use of a non-rebreather mask in the SARS-CoV-2pandemic. Chest X-ray showed large right pneumothorax and extensive interstitial disease. Hypoxemia continued despite chest tube placement necessitating emergent intubation. CT chest was obtained and nasopharyngeal SARS-CoV-2 PCR was positive. HIV serology was positive and absolute CD4+ count was 32 cells/cubic mm.

Given his severe acquired immunodeficiency, radiographic findings were concerning for a life-threatening coinfection with Pneumocytis jirovecii and treatment with trimethoprim/sulfamethoxazole, prednisone, and remdesivir was started. Four days later Pneumocystis pneumonia (PCP) coinfection was confirmed by bronchoscopic Pneumocystis antigen. The patient clinically improved and was successfully extubated 21 days later.

Multifocal ground-glass opacities are principal findings in both PCP and SARS-CoV-2 infections making radiographic differentiation potentially difficult, especially in immunocompromised hosts. Cystic lesions can occur in one third of patients with advanced PCP. In absence of these cystic radiographic findings, diagnosis of PCP coinfection would have been arduous. Therefore awareness of coinfections is critically important in the current SARS-CoV-2 pandemic to properly diagnose and subsequently treat these coinfections thereby reducing morbidity and mortality.