Introduction: HIV patients can be a diagnostic challenge since they present with non-specific symptoms and atypical clinical presentations due to a muted immune response. They are at risk for developing opportunistic infections and malignancies which complicates clinical course. This warrants us to maintain a high index of suspicion and a multifaceted diagnostic approach.
Description: A 54-year-old male with a history of HIV (viral load: 33 copies/mL, CD4 34 %) on ART presented with a two-day history of altered mental status and fever. Laboratory findings showed leukocytosis with neutrophil predominance, lymphopenia, lactic acidosis and elevated CRP. Initial infectious workup including imaging was negative. Empiric antibiotics were initiated. Lumbar puncture performed showed CSF studies concerning for bacterial meningitis. CSF culture grew Streptococcus pneumoniae, susceptible to Rocephin and was positive for CMV antibody IgG. He clinically improved with Rocephin, but mentation declined after completing antibiotic course. MRI Brain showed cerebritis. Repeat lumbar puncture showed normal glucose, elevated protein, elevated WBC, neutrophilia, lymphopenia along with positive CMV by PCR in CSF and serum. He was initiated on ganciclovir, which drastically improved the patient's mentation.
Discussion: This case highlights the diagnostic challenges in immunocompromised patients who have muted immune responses with non-specific symptoms. This patient initially presented with altered mentation suggestive of an infectious etiology, with CSF studies confirming Streptococcus pneumoniae meningitis, which improved with Rocephin. Further deterioration in clinical status prompted further workup including an MRI Brain which showed cerebritis and a repeat lumbar puncture showing neutrophilic prominence, which eventually grew CMV. One notable aspect from the diagnostic is that the patient was chronically lymphopenic which might have muted the lymphocyte response in the CSF studies and masked the secondary infection. This is reiterating the diagnostic dilemma in recognizing infections with overlapping symptoms and the importance of methodical approach for appropriate patient care. This emphasizes the importance of proactive preventative strategies such as vaccinations and ART to reduce the risk of severe infections.
