Hidden danger: four lung infections in late-stage HIV

People living with advanced HIV infection can face more than one dangerous lung infection at the same time. Ivan V. Shashenkov and colleagues set out to describe the clinical picture and diagnostic challenges when disseminated pulmonary tuberculosis occurs together with coronavirus (CVP), pneumocystis (PCP) and pneumococcal (PCcP) pneumonia. The study was prospective and included 120 newly diagnosed patients aged 29–53 years who had disseminated pulmonary tuberculosis with isolation of Mycobacterium tuberculosis and were in IVB stage of HIV infection in the progression phase, without antiretroviral therapy. Patients were randomized into main and comparison groups labeled 1A, 2A and 1B, 2B. The 1A group included 29 patients with comorbidity of disseminated pulmonary tuberculosis, coronavirus and pneumocystis pneumonia; 2A had 31 patients with disseminated pulmonary tuberculosis, CVP and PCcP. The 1B and 2B groups included 29 and 31 similar patients respectively, but without CVP. The investigators focused on how these infections overlap in people with severe immunodeficiency and how that affects clinical signs, imaging and the need for careful diagnostic testing.

To identify the specific causes of pneumonia the team used established laboratory and microbiological methods. PCR for SARS-CoV-2 RNA was used in naso- and oropharyngeal swabs, in sputum or in endotracheal aspirate to diagnose CVP. For detection of Pneumocystis jirovecii the causative agent of PCP, they performed microscopic examination of diagnostic material from the respiratory tract with staining according to Romanowsky-Giemsa and according to Grocott-Gomori. For detection of Streptococcus pneumoniae, the causative agent of pneumococcal pneumonia, diagnostic material was sown on special nutrient media, with the determination of drug resistance of the obtained culture to broad-spectrum antibiotics. Statistical data processing was carried out using Microsoft Office Excel 2019 with calculation of mean value of the indicator in the group, standard error and confidence interval. The researchers found that these coinfections were linked to severe immunodeficiency, generalized tuberculosis with multiple extrapulmonary lesions and severe pneumonia, and that clinical signs and respiratory symptoms were similar across infections.

The study highlights a practical problem: when tuberculosis, CVP, PCP and PCcP occur together they produce overlapping symptoms and complex computed tomographic changes, making it hard to distinguish which pathogens are present from clinical signs or CT alone. The reported CT picture involved a simultaneous combination of four pathological syndromes: dissemination, pleural pathology, increased pulmonary pattern and adenopathy. Because several diseases can look the same on imaging and in symptoms, the authors emphasize the need for a complex etiological diagnosis using targeted laboratory tests so that clinicians can prescribe timely, combined treatment. For people with disseminated pulmonary tuberculosis and advanced HIV, the findings underline the importance of active screening and rapid laboratory confirmation to allow emergency hospitalization and appropriate therapy with the goal of reducing mortality in this vulnerable group.