Pneumocystis carinii pneumonia, pulmonary tuberculosis and visceral leishmaniasis in an adult HIV negative patient

this is a case report of a 29 year old male with pneumocystis pneumonia and tuberculosis, and who was initially suspected of having hiv infection, based on risk factor analyses, but was subsequently shown to be hiv negative. the patient arrived at the hospital with fever, cough, weight loss, loss of appetite, pallor, and arthralgia. in addition, he was jaundiced and had cervical lymphadenopathy and mild heptosplenomegaly. he had interstitial infiltrates of the lung, sputum smears positive for mycobacterium tuberculosis and pneumocystis carinii, and stool tests were positive for strongyloides stercoralis and schistosoma mansoni. he was diagnosed as having aids, and was treated for tuberculosis, pneumocystosis, and strongyloidiasis with a good response. the patient did not receive anti-retroviral therapy, pending outcome of the hiv tests. a month later, he was re-examined and found to have worsening hepatosplenomegaly, pancytopenia, fever, and continued weight loss. at this time, it was determined that his hiv elisa antibody tests were negative. a bone marrow aspirate was done and revealed amastigotes of leishmania, and a bone marrow culture was positive for leishmania species. he was treated with pentavalent antimony, 20 mg daily for 20 days, with complete remission of symptoms and weight gain. this case demonstrates that immunosuppression from leishmaniasis and tuberculosis may lead to pneumocystosis, and be misdiagnosed as hiv infection. the occurrence of opportunistic infections in severely ill patients without hiv must always be considered and alternate causes of immunosuppression sought.