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"An Intruder Is Causing a Hollow in My Lung": A Rare Case of Necrotizing Pneumonia in an Immunocompromised Patient

Despite active antiretroviral therapy (ART), community-acquired bacterial pulmonary infections remain one of the most opportunistic infections in patients with HIV infection. Necrotizing pneumonia is a rare and serious complication of bacterial community-acquired pneumonia (CAP) characterized by pulmonary consolidation with multiple small lung cavities and parenchymal necrosis. Pseudomonas aeruginosa is not a frequent pathogen of necrotizing acute CAP and data regarding its management is limited. Based on the severity of clinical presentation and presence of P. aeruginosa infection risk factors, broader empiric antibiotic therapy can be provided. We present the case of a 39-year-old woman with medical history of HIV diagnosed since 2012 on emtricitabine/tenofovir and raltegravir who presented to the urgency department due to non-productive cough of 3 days of evolution. Also reported dyspnea, fever, chills, fatigue and general malaise. She denied night sweats, hemoptysis, weight loss, and diarrhea. Vitals signs remarkable for tachycardia, tachypnea, and hypotension. Physical examination remarkable for respiratory distress, dry oral mucosa and diffuse bilateral rhonchi. ABG showed respiratory alkalosis accompanied with hypoxemia and elevated A-a gradient. CBC remarkable for leukocytosis with bandemia, monocytosis and lymphopenia with microcytic anemia and normal platelets. Inflammatory markers including CRP, ESR and fibrinogen were elevated. Coagulation was prolonged. Chemistry remarkable for hypotonic hypovolemic hyponatremia, moderate hypokalemia, elevated lactate dehydrogenase, hypoalbuminemia and very high alkaline phosphatase. SARS-COV 2 PCR was negative. Chest CT showed bilateral patchy densities, right consolidate and multiple cavitation at the right upper lung field. Patient was initially treated with lung protective mechanical ventilation, vasopressors and empiric broad spectrum antibiotics. Sputum culture grew pseudomonas aeruginosa. Other laboratories such as acid fast and influenza were negative. Blood culture was also positive for pseudomonas aeruginosa. P. aeruginosa is a rare cause of necrotizing pneumonia. In the past, streptococcus pneumoniae caused 95% of CAP, however today is only detected in only 10-15% of inpatients cases in United States. Other etiologies for CAP include Haemophilus influenzae, staphylococcus aureus, Moraxella catarrhalis and less commonly P. Aeruginosa. P. Aeruginosa is responsible of 5-7% of cases of CAP in HIV patients. Blood cultures are positive in about 20 to 25% of inpatients with pneumococcal pneumonia but in fewer cases of pneumonia caused by H. influenzae or P. aeruginosa. P. aeruginosa is associated with high mortality and poor prognosis in immunocompromised patients and septic shock. The aim of this case is to raise awareness of pseudomonas necrotizing pneumonia for early detection, adequate management and better outcomes.