Female, 42 years old. She presented 8 months with recurrent herpes in the mouth.
Admitted for 2 months with a dry cough and rapidly progressive dyspnoea. In addition, bilateral chest pain, fever up to 39oC and weight loss of 14kg. The recurrence of the herpetic lesion caused dysphagia and odynophagia.
Physical examination revealed whitish plaques in the oropharynx; chest examination revealed decreased breath sounds and fine rales. On room air, oxygen saturation was 86%. The arterial blood gas report with 70% supplemental oxygen was: pH 7.30, pCO2 40.5mmHg, pO2 132mmHg, HCO3 19.5mmol/l, base excess -5.8mmol/l, oxygen saturation 97.9%. Oxygenation index (OI) of 188. Laboratory tests on admission showed: lymphopenia of 600 cells/mm3, Hb 11.8g/dl, lactate dehydrogenase 971IU/l and albumin 3.3g/dl.
Chest X-ray showed bilateral patchy opacities with ground glass and pneumomediastinum, so the differential diagnosis included HIV-associated immunosuppression and P. jirovecii pneumonia (PJP). The ELISA test for HIV was POSITIVE, confirmed by Western Blot.
Bronchoscopy with transbronchial biopsy and bronchoalveolar lavage (BAL) was performed. The histopathological study is reported in figure 1. He received treatment with Trimethoprim/Sulfamethoxasol and Prednisone in reduction doses for 21 days.

On the 7th day of treatment he presented respiratory deterioration and the OI dropped to 110, for which he was admitted to intensive care in shock and supported with invasive mechanical ventilation. On admission, laboratory tests showed leukocytes of 24,300 cells/mm3, Hb 10.8g/dl, lactate dehydrogenase 2033 IUI/l and albumin 2.26g/dl. Imipenem was added on suspicion of hospital-acquired pneumonia and after 12 days the leukocyte count improved to 5800 cells/mm3, Hb 8.7g/dl, lactate dehydrogenase 879 IUI/l, albumin 2.41g/dl and OI 243.5, and extubation was achieved.
In the following 24h, he presented massive haemoptysis (volume 250ml). Hb decreased to 6g/dl, OI decreased to 106 and he was supported with invasive mechanical ventilation. Swan-Ganz measured a POAP of 10mmHg. Chest X-ray is shown in figure 2A. He underwent LBA whose pathology study confirmed the presence of recent and active alveolar haemorrhage. In addition, rt-PCR documented CMV infection and he started treatment with Ganciclovir 350mg/d for 14 days.

He had a good evolution, improving the OI to 277 and withdrawing from invasive mechanical ventilation 9 days after the event. After 37 days he was discharged home. At follow-up, the CD4 count was 109 cells/µL and the viral load <40 cells/µL.

