32-year-old male with a recent diagnosis of COVID-19 by reverse transcription polymerase chain reaction (RT-PCR) and past medical history of HIV on highly active antiretroviral therapy (Bictegravir/emtricitabine/tenofovir alafenamide) and epilepsy on Lamotrigine, presented to the hospital with cough. He reported being in his usual state of health until approximately a few days before the presentation, where he noted a cough with brownish sputum production and shortness of breath with minimal exertion. He also endorsed night sweats, chills, and fever; however, he denied any weight loss, chest pain, dysuria, diarrhea, abdominal pain, sick contacts, or recent travels.
On arrival, he was febrile otherwise vital signs stable as he was on room air. Labs were unremarkable except for transient leukocytosis of 14.6 k/uL with 75.5% neutrophils and CRP 229 mg/L. RT-PCR COVID-19 test was double negative. CD4 absolute count was at 609 cells/microL.
Of note, he was recently discharged from the emergency department two weeks prior to presentation after testing positive for COVID-19. He presented with body aches, nasal congestion, and a sore throat. He also reported anosmia and ageusia. Otherwise, he denied chest pain, shortness of breath, or fever. He saturated well on room air and was only managed with supportive measures.
He worked at a warehouse and was incarcerated more than ten years ago. He had a previous history of polysubstance abuse and currently only endorses smoking marijuana occasionally. He is an active tobacco user with eight packs a year. He had received two shots of the COVID-19 Moderna vaccine. He has not had any seizure episodes during the past year.
A chest x-ray revealed a 5 cm cavitary infiltration involving the superior segment of the left lower lobe with no previous chest x-ray for comparison (Fig. 1 ). Computed tomography (CT) scan of the chest with IV contrast (Fig. 2 ) showed a thick-walled gas-filled cavitary lesion measuring 5.4 x 4.8 cm in the superior segment of the left lower lobe. Given his history of HIV, tuberculosis was suspected. However, multiple testing with Acid Fast Bacilli (AFB) and QuantiFERON TB Gold were negative. He was started on Vancomycin and Piperacillin / Tazobactam pending cultures. Subsequent workup, including blood and respiratory cultures, urine Streptococcus and Legionella antigen, Cryptococcal serum antigen, (1,3) Beta-D-glucan and Galactomannan antigen, were unremarkable. He had non-reactive ANA and ANCA, C3 and C4 complement levels within the normal range. Percutaneous CT-guided co-axial core needle biopsy was done during admission with pathology (Figs. 3 and 4 ), showing benign alveolated lung parenchyma with changes consistent with organizing pneumonia. AFB and fungal culture from lung biopsy tissue were negative. Anti-biotics were discontinued as there was low suspicion of active bacterial infection. Given that he was no longer symptomatic, he was discharged with a follow-up with his primary care physician and pulmonologist.