Severe unexplained HIV seronegative immune suppression (SUHIS) with invasive aspergillosis and candidiasis

Background: HIV/AIDS infection is typically associated with a low CD4 count. In general CD4 count is a marker of clinical progression and management of the disease. HIV/AIDS is also associated with CD4/CD8 ratio of less than 1 and hypergammaglobulinemia. Emerging reports of CD4 lymphopenia in the absence of evidence of HIV -1 or HIV -2 infections led to a new clinical entity called Severe Unexplained HIV- seronegative immune suppression(SUHIS) by the World Health Organization. We report a case of SUHIS in a 30 year old man with Invasive Aspergillosis and Candidiasis. Case Report: A 30 year old male with no significant past medical history presented with worsening right sided chest pain, productive cough, and shortness of breath of two weeks duration. He was incarcerated few months prior to presentation where he had a negative PPD and HIV test. He reported a 15 pack year history of cigarette smoking in addition to smoking "rolled up tissue paper" in jail. After initial investigations, he was found to have right cavitary lung lesions secondary to invasive aspergillosis, oropharyngeal candidiasis and a very low CD4 count which was suggestive of immunosuppression. Further investigations confirmed his diagnosis of SUHIS. He was treated with fluconazole for candidiasis and amphotericin/ voriconazole for aspergillosis. Conclusions: SUHIS is defined exclusively by CD4 count of less than 300/mcL or < 20% of total T cells on two occasions, in the absence of HIV infection and the presence of opportunistic infection, indicative of cellular immune deficiency.