Opportunistic infections (OIs) have been reported to be more frequent and severe in individuals with human immunodeficiency virus (HIV) infection due to immunosuppression [1]. OIs typically manifest 7 to 10 years post-infection. Before the launch of effective antiretroviral therapy (ART) [2], most patients survived for only 1 to 2 years after manifestation of acquired immune deficiency syndrome (AIDS) [3].
Simultaneous diagnoses of Pneumocystis jirovecii pneumonia (PCP), Cryptococcus neoformans infection, and lymphoma in patients with HIV are rare and have been observed in individuals with severely compromised immune systems. The present case study offers valuable insights into the management of these complexities.
A 38-year-old male presented with a 6-month history of weight loss and anorexia. He was identified as HIV-positive 12 years ago during a blood donation screening. The patient had multiple heterosexual relationships without consistent condom use, which prevented him from seeking treatment. He lost 30 kg over 6 months and experienced profound weakness. Three days prior to admission, the patient was diagnosed with candidiasis.
On admission, his CD4 count was 32 cells/μL, and HIV RNA viral load was 2,200,000 copies/mL. Chest computed tomography (CT) revealed atypical pneumonia suggestive of PCP (Fig. 1A). The patient was started on bictegravir/emtricitabine/tenofovir (one tablet daily). On the day 3 of admission, his bronchoalveolar lavage fluid tested positive for Pneumocystis jirovecii by polymerase chain reaction. On the 4th day after admission, enhanced abdominal pelvic CT revealed multiple enhancing masses in both hemilivers and an irregular mass in the ascending colon (Fig. 1B, C). Blood culture revealed fungemia on the 5th day of admission; Cryptococcus neoformans was identified from the blood culture on the 7th day of admission and was tested to be susceptible to amphotericin and flucytosine. HIV drug resistance mutation testing did not reveal any resistance mutations in the HIV drug classes. A colonoscopy performed on the 11th day after admission revealed an ingrowing mass extending from the terminal ileum to the proximal ascending colon (Fig. 1D). On the 14th day after admission, a biopsy of the colon specimens confirmed high-grade B-cell lymphoma, and ascitic fluid analysis confirmed B-cell lineage lymphoma (Fig. 2). On the 20th day after admission, positron emission tomography-CT revealed highly probable malignant lesions throughout the body (Fig. 1E). Despite treatment with susceptible HIV drugs and management of opportunistic diseases, the patient had to be transferred to the intensive care unit because of rapidly progressing multi-organ failure and subsequently he died on the day 20 of admission (Fig. 1F).
This report highlights the importance of early diagnosis and treatment adherence in the management of HIV infections and the prevention of OIs. The patient presented with severe immunosuppression, highlighted by a CD4 T cell count below 200 cells/μL, facilitating the simultaneous occurrence of PCP, Cryptococcus neoformans infection, and high-grade B-cell non-Hodgkin lymphoma. These conditions reflect advanced HIV infection and underscore the devastating impact of untreated HIV infections. In addition, the Korean domestic cohort study reported that syphilis accounted for 27.5% of AIDS-defining diseases, followed by tuberculosis (16.2%), PCP (8.7%), and extrapulmonary cryptococcosis (0.4%) [4]. Notably, only one patient in the cohort was diagnosed with Burkitt lymphoma, and there have been no recent reported cases of non-Hodgkin lymphoma, underscoring the uniqueness of this case. In addition, the simultaneous occurrence of PCP, Cryptococcus neoformans infection, and high-grade B-cell lymphoma, as observed in this patient, is exceptionally rare.
Among the 19,745 individuals infected with HIV in 2023 in South Korea, 16,467 are alive [5]. Approximately 84% of them live without significant health issues owing to appropriate treatment [5]. The 2023 HIV/AIDS Reporting Status in South Korea estimated a survival rate of 83.4% for individuals with HIV. The mortality rate among HIV-infected individuals was 4.0% between 2001 and 2015. Implementation of the first Korean AIDS Prevention and Control Plan (2019-2023) led to an increase in the proportion of HIV-infected individuals receiving treatment, from 94.7% in 2019 to 96.2% in 2022. In addition, the viral suppression rate of those receiving treatment has increased from 94.9% in 2019 to 96.2% in 2022 [6]. The goals set by the Joint United Nations Programme on HIV/AIDS (UNAIDS) state that by 2025, 95% of individuals living with HIV should be aware of their status, 95% of those diagnosed should be receiving treatment, and 95% of those receiving treatment should achieve viral suppression. These targets highlight the global commitment to improve HIV care and management. Despite success in certain regions, several countries still fall behind the UNAIDS targets; for instance, only 67% of individuals with HIV globally accessed treatment in 2019. Although South Korea has met these criteria, early diagnosis needs to be increased, and continued surveillance and policies are warranted to achieve this goal in the future, highlighting significant barriers to effective HIV management. The delay in seeking care and initiating ART in this patient was primarily attributed to the fear and stigma associated with HIV infection. To improve outcomes, developing robust follow-up and support systems for public and community interests in individuals diagnosed with HIV is imperative. These systems should include comprehensive education about the disease, the importance of ART adherence, and regular monitoring of immune status.
In conclusion, this case highlights the urgent need for interventions that facilitate early treatment and continuous care of HIV-infected patients. Healthcare providers can significantly improve the prognosis of individuals living with HIV by addressing barriers such as stigma and lack of awareness and implementing systematic follow-up protocols.
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