Pulmonary tuberculosis and pneumocystis jirovecii concurrent pneumonia in HIV infected patients at a resource limited setting in Eastern India: A case series.

Pneumocytis jirovecii pneumonia (PJP) and Pulmonary TB (PTB) both are common opportunistic infections among HIV infected individuals. But concurrent infections pose a diagnostic challenge owing to similar clinical features. Data suggests a high prevalence of such concurrent infections in developing countries but limited diagnostic modalities especially in resource constraint setup limits accurate diagnosis. At our centre we came across 6 newly diagnosed PTB patients among HIV infected ones had persistent shortness of breath (SOB) and hypoxia despite starting anti-tuberculous treatment (ATT). We excluded concomitant bacterial pneumonia by imaging, sputum examination and blood culture. Serum lactate dehydrogenase (LDH) was estimated and hypoxia by arterial blood gas (ABG). We found all 6 patients had elevated serum LDH, hypoxia and imaging suggestive of PJP were offered sputum for Geisma stain and standard treatment for PJP in form of Bactrim-double strength and steroid. 1 patient had PJ cysts in sputum. 5 patient's classical radiologic findings in form of ground glass opacities in lower lobes along with bilateral infiltrates and 1 had honeycombing. Serum LDH was elevated all 6 subjects. 5 were newly diagnosed HIV and 4 had CD4 count below 50 cells/mm3 and 2 had below 200 cells/mm3.1 patient had developed bilateral pneumothorax as complication. 4 patients responded to treatment and 2 (33.3%) died of respiratory failure during treatment. We were able to diagnose only severe PJP cases as concurrent infection with PTB as there was no availability of broncho alveolar lavage (BAL) as well as direct fluorescent antigen (DFA) test for PJ detection. A high index of suspicion for PJP even in PTB patients with low CD4 count will guide to appropriate therapy for both infections and eventually reduces morbidity and mortality.

Concomitant falciparum malaria and Hyperreactive Malarial Splenomegaly in an adolescent boy from eastern India: A tale of rare coincidences.

Hyperreactive malarial splenomegaly (HMS) is one of the important causes of massive splenomegaly in malaria endemic zones. It is thought to represent a dysfunctional immune response to recurrent malarial infection. It is usually reported due to physical symptoms of splenomegaly and hypersplenism and fever is classically absent. Concomitant malaria with HMS is a very rare finding in the Indian context. Here, we report a case of symptomatic falciparum malaria presented with fever, jaundice, massive splenomegaly and pancytopenia. Persistent massive splenomegaly led us to investigate thoroughly and finally diagnosed it as HMS with concomitant falciparum malaria. He received standard antimalarial treatment and 12 months of weekly chloroquine and completely recovered without any relapse or complications.