Case 2-2017: An HIV-Positive Patient with COPD Admitted to the ICU with Respiratory Failure

Dr Bhavani Puskur (Infectious Diseases (ID) fellow): A 54-year-old male active smoker with a history of chronic obstructive lung disease (COPD) on 2 L/min of home oxygen and human immunodeficiency virus-1 (HIV) on antiretroviral therapy with a recent CD4 count of 482 (26%) cells/cc and a suppressed viral load, presented to the Emergency Room (ER) of University of Louisville Hospital with a cough productive of thick, yellow phlegm, dyspnea for 4 days and chest tightness for one day. He complained of having a sore throat, rhinorrhea and nasal congestion during the previous week. He had been using his inhalers at home without significant relief. He denied fever or chills. He had been to the ER multiple times with worsening dyspnea and nonproductive cough, which improved with prednisone and bronchodilators. He declined frequent admission, but this was his third visit to the ER in the last two days; each via emergency medical services transportation. In the ER, his temperature was 36.6°C, blood pressure was 210/141 mmHg, heart rate was 120 beats/min, and respiratory rate 16/min. His oxygen saturation was 98% while wearing a non-rebreather mask. On physical examination, there was no pharyngeal erythema or exudate and sinuses were nontender. He had pursed lip breathing with significant inspiratory wheezing. After administration of a breathing treatment and steroids, there was improved aeration throughout all lung fields with decreased, but still diffuse, expiratory wheezing. A chest X-ray was obtained. (Figure 1) His electrocardiography was unchanged, and troponins were negative. He was admitted to the Intensive Care Unit (ICU) for use of non-invasive ventilation.