Review Question - QID 104894

This patient with HIV infection and recent fever, cough, and shortness of breath likely has community-acquired pneumonia (CAP). Similarly to immunocompetent patients, the most common cause of CAP in patients with HIV is Streptococcus pneumoniae.

CAP commonly presents with fevers, chills, productive cough, and shortness of breath. The most common identified pathogen in patients with CAP is Streptococcus pneumoniae; however, in many cases no pathogen is identified. Other common causes include Haemophilus influenzae, Moraxella catarrhalis, Mycoplasma pneumoniae, and other viral pathogens. Patients that are living with HIV are at risk for other, less common causes of pneumonia or other infections. The most common cause of CAP in patients with HIV is Streptococcus pneumoniae. Management of CAP typically consists of inpatient admission with intravenous antibiotic therapy. Empiric coverage for CAP is with ceftriaxone for coverage of Streptococcus pneumoniae, as well as azithromycin for coverage of atypical pathogens such as Mycoplasma pneumoniae (there are many other antibiotic regimens). Most patients improve with antibiotics after several days.

Almeida et. al review the management of community acquired pneumonia in patients with HIV. They further discuss differences in microbiology for pneumonia in patients with HIV in comparison to immunocompetent patients. They discuss options for antibiotic therapy in outpatient and hospitalized patients.

Figure A is a chest radiograph suggestive of lobar pneumonia with left lower lobe consolidation.

Incorrect Answers:
Answer 1: Cytomegalovirus pneumonia typically presents with diffuse pulmonary infiltrates and commonly occurs as a co-infection with opportunistic pathogens; however, infection with S. pneumoniae is still the most common cause of pneumonia in patients with HIV.

Answer 2: Klebsiella pneumoniae pneumonia is a less common cause of CAP, and is more often associated with aspiration pneumonia. “Currant jelly” sputum is a characteristic finding, and alcoholics are at particularly increased risk.

Answer 3: Mycobacterium tuberculosis often causes pneumonia as a primary infection. However, patients typically have a less acute course with associated night sweats, hemoptysis, and weight loss over the course of several weeks.

Answer 4: Pneumocystis jiroveci may cause pneumonia in patients with poorly controlled HIV. It is more common in those with HIV who have CD4+ T cells counts less than 200 cells/uL. On chest radiograph, it typically appears as a more diffuse infiltrative pattern. Furthermore, it generally follows a less acute course.

Bullet Summary:
Just as in immunocompetent patients, the most common cause of community acquired pneumonia in patients with HIV is Streptococcus pneumoniae.