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.