Recurrent Sinopulmonary Infections in a Patient Whose HIV Masked Common Variable Immunodeficiency
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Division of General Internal Medicine, Harborview Medical Center, University of Washington , Seattle , WA , USA; 2Department of Medicine, Oregon Health & Science University , Portland , OR , USA; 3Division of Gastroenterology, Department of Medicine, Oregon Health & Science University , Portland , OR , USA; 4Division of Hospital and Specialty Medicine, VA Portland Health Care System, Oregon Health & Science University , Portland , OR , USA; 5Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University , Portland , OR , USA.
It is generally accepted that persons infected with human immunodeficiency virus (HIV) are at an increased risk of infection due to direct destruction of CD4+ lymphocytes and subsequently impaired cell-mediated immunity. Typically, HIV infection is associated with immunoglobulin elevations, but quantitative deficiencies in immunoglobulins have also been rarely described. We present an unusual case of common variable immunodeficiency (CVID) in a HIV-positive patient with recurrent severe respiratory infections. We review epidemiology, clinical presentation, and treatment of primary immunoglobulin deficiency. We also review the relationship between immunoglobulin deficiency and HIV and highlight the importance of recognizing the coexistence of two distinct immunodeficiency syndromes. KEY WORDS: HIV/AIDS; diagnosis; immunology. J Gen Intern Med DOI: 10.1007/s11606-019-05435-3 © Society of General Internal Medicine 2019
Sinopulmonary Infections in a Patient Whose R ecurrent HIV Masked Common Variable Immunodeficiency CASE
A 34-year-old man with a history of HIV presented with a threeday history of recurrent dyspnea, wheezing, and unproductive cough. Three weeks prior, he had been hospitalized for respiratory failure, requiring Bi-level positive airway pressure support (BiPap), and was diagnosed with viral pneumonia and an asthma exacerbation. His HIV infection was well-controlled, with a recent CD4+ count of 537 cells/mm3, undetectable HIV RNA, and no prior opportunistic infections. Additional medical history was significant for asthma, chronic rhinosinusitis, major depressive disorder, and six hospitalizations in the last year for recurrent pneumonia and asthma exacerbations. During these hospitalizations, the only causative pathogens recognized were metapneumovirus and rhinovirus. No bacterial or fungal pathogens were identified; however, the patient received empiric
antibiotic coverage for community acquired and healthcareassociated pneumonia on multiple occasions. The patient was a former tobacco user, and he intermittently used intravenous methamphetamine and inhaled cocaine. Family history was significant for asthma, alcohol use disorder, and coronary artery disease. His medications included abacavir-lamivudine, raltegravir, albuterol inhaler, fluticasone-salmeterol inhaler, montelukast, buprenorphine-naloxone, clonazepam, citalopram, mirtazapine, and olanzapine. He was allergic to trimethoprimsulfamethoxazole. On presentation, his heart rate was 140 beats per mi
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