Discussion
Opportunistic infections caused by bacteria and fungi are common in
human immunodeficiency virus (HIV)-infected patients. Cryptococcosis is
one of the fungal diseases caused by Cryptococcus neoformans with higher
prevalence in immunocompromised patients, especially in those with
advanced HIV infection and CD4 T lymphocyte cell (CD4) counts lower than
100 cells/mm3,for whom fungaemia has been associated with a poor
prognosis (4)(5). Many other infections have been characterized as
opportunistic infections secondary to HIV infection, these include, but
are not limited to, infections with Toxoplasma gondii, Pneumocystis
jiroveci pneumonia (PCP), Cytomegalovirus (CMV), and
Mycobacterium avium complex (MAC).
Furthermore , Pneumocystis jiroveci pneumonia (PCP) is major
AIDS-related opportunistic infection, particularly in patients with
advanced immunosuppression (CD4 count <200/µL) in whom human
immunodeficiency virus (HIV) infection remains undiagnosed or untreated
(6).
Similarly, Non-tuberculous mycobacteria (NTM) are also important causes
of pulmonary and extrapulmonary disease in immunosuppressed hosts
(7)(8). Distinguishing it from other opportunistic infections that
occurred earlier in the course of HIV infection, for example
disseminated Mycobacterium avium complex (MAC) was associated with very
low CD4+ counts, generally below 50 cells/mm3 (9).
Simultaneous infections with Cryptococcus neoformans together with
Mycobacterium as well as Pneumocystis jiroveci pneumonia (PCP) are rare,
and typically occur in immunocompromised individuals, particularly AIDS
patients when the CD4 lymphocyte count found to be as low as
3-20/microliters , mainly if co-infection with Cryptococcus neoformans
and Mycobacterium exist together (10).
In our case the patient newly found to have HIV with CD4 lymphocyte
count was not sent as the patient loss the follow and travel back to his
home country but he was found to have high viral load ( > 6
million ) , which indicate severe disease , and can explain the presence
of Cryptococcus neoformans fungaemia, which it’s self very rare to be
found alone. At the same time, it can explain the co-infection by
Cryptococcus neoformans and Non-tuberculous mycobacteria (NTM) which is
also infrequent in HIV infected patients. Not only that, but existence
of third infection in form of Pneumocystis jiroveci pneumonia (PCP) make
our case is extremely rare. in addition, of positive PCR from BAL for
Both CMV and EBV, and reactive Treponema pallidum antibodies, make the
presence of other opportunistic and sexual transmitted infections is
more likely in our patient.