The patient was a 35-year-old African American female with a history of asthma and polysubstance abuse who presented to the emergency department (ED) with severe shortness of breath. She reported that the shortness of breath was progressive over several months and associated with weight loss. She denied a history of HIV infection. The patient's only known home medication was albuterol as needed for asthma. She also reported a history of smoking 10 cigarettes a day and drinking alcohol a couple of times a week.
On physical examination, she was cachectic, ill-appearing and tachypneic with the use of accessory muscles for respiration. Her blood pressure was 88/55 mm Hg, temperature was 37.4 C, pulse rate was 146 beats per minute and regular, oxygen saturation of 70% on room air, and body mass index of 18.9. Lung auscultation revealed bilateral rhonchi. Heart auscultation revealed normal S1 and S2 without significant murmurs or rubs. She was placed on a non-rebreather mask with FiO2 of 100% without improvement of respiratory status and was switched to non-invasive mechanical ventilation. Her status continued to decline, and she underwent endotracheal intubation within an hour of arriving at the ED for hypoxic respiratory failure. SARS-CoV-2 testing done upon arrival in the ED was negative. She tested positive for HIV, and further evaluation revealed an initial viral load of 343,636 copies per milliliter and an absolute CD4 count of 5 cells/muL.
On day 1, a chest radiograph (Figure 1(a)) revealed extensive right lung opacities, most prominent in the right middle lobe. The cardiac silhouette was slightly enlarged. A chest CT scan with intravenous contrast (Figure 2) revealed severe cavitary and partially necrotic opacities in the right upper lobe. There was also a small right pleural effusion and a moderate pericardial effusion. An echocardiogram (Figure 3) revealed a large pericardial effusion, as large as 4.16 cm, with no signs of tamponade.
Initially, she was placed on vancomycin, cefepime, azithromycin, anidulafungin, trimethoprim/sulfamethoxazole (TMP/SXM) and methylprednisolone. She also required norepinephrine and vasopressin for the first 5 days for hypotension, most likely due to septic shock. On day 5, she underwent bronchoscopy for BAL after tuberculosis was ruled out with three negative sputum acid-fast bacillus smears and a negative polymerase chain reaction (PCR) test. Chest radiography on day 8 (Figure 1(b)) revealed an increase in the right-sided infiltrates and new patchy infiltrates at the left lung base.
On day 13, PCR of the BAL was positive for CMV with CMV DNA of 197,000 IU/mL. Fungal culture of the BAL fluid did grow Candida albicans, which was determined to be a colonization. All other tests performed on the BAL (summarized in Table 1) were negative. Additionally, tests for Cryptococcus antigen, Histoplasma antigen, Legionella antigen, A. Galactomannan antigen and (1,3)-beta-D-glucan were negative. She was started on IV ganciclovir 250 mg twice a day for CMV pneumonia and antiretroviral therapy for HIV. Anidulafungin, methylprednisolone and all other antibiotics were discontinued except for TMP/SXM, which was continued for Pneumocystis jiroveci pneumonia (PJP) prophylaxis. She was extubated on day 13 and switched to high-flow nasal cannula. 
On day 17, a follow-up echocardiogram showed that she still had a large circumferential pericardial effusion that had not changed significantly in size since the day of admission. Pericardiocentesis was performed, draining 500 mL of straw-colored fluid. Pericardial fluid analysis was positive for CMV DNA using PCR and negative for adenosine deaminase. All other tests performed on the pericardial fluid (summarized in Table 1) were negative.
A chest radiograph on day 22 (Figure 1(c)) showed reduced infiltrates in the right lung field, with a moderate overlying pleural effusion. Her HIV viral load had decreased to 5,522 RNA copies per milliliter. She was breathing comfortably on room air. She was discharged on oral valganciclovir 900 mg twice a day until her CD4 count improved to over 100 cells/muL, TMP/SXM for PJP prophylaxis and Biktarvy as antiretroviral therapy.