A 40-year-old woman with HIV+, diagnosed 4 years ago during a pregnancy (the only moment she received antiretroviral treatment), who came to the hospital with respiratory failure of two weeks duration.
The initial examination revealed dry cough, crackles in both bases and fever.
The patient had no other relevant backgrounds, respiratory diseases in close relatives, or recent trips.
No enlarged lymph nodes, heart failure or deep venous thromboembolism were observed.
At the last follow-up visit, 6 months prior to admission, she had 49 5 x 106/L CD4 count and a viral load of 51,000 copies.
On admission, these figures were 129 x 106/L CD4 (16%) and 330,000 copies.
The initial evolution was torpid, with progressive respiratory distress.
Chest X-ray showed a reticular-interstitial pattern and pulmonary scintigraphy ruled out pulmonary thromboembolism.
Sputum samples were collected and fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) was performed.
Intravenous cotrimoxazole + levofloxacin were initiated, but quinolone was withdrawn due to the subsequent finding of P. jirovecii in the LAB.
Twenty-four hours after starting antibiotic treatment, the patient improved markedly, decreased the demand for O2, and on the sixth day oral treatment was started.
At 11 days, a non-pruriginous erythematous cutaneous eruption appeared on the back and neck, together with a fever of 39° C, the patient developed a clinical picture suggestive of an allergic reaction.
However, given the good evolution of pneumonia and the disappearance of rash and fever at 48 h, the possibility of administering trimethoprim and oral dapsone was assessed as an alternative to the continuation of outpatient cotrimoxazole treatment.
However, 24 h after dapsone administration, the patient developed a rash morbilliform and fever, so oral treatment was withdrawn and treatment with pentamidine IV ended.
