Navigating an Acute presentation of HIV/AIDS on a Young Adult

Date

2024-03-21

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BACKGROUND: The initial stage of human immunodeficiency virus (HIV) infection can resemble mononucleosis, showcasing various nonspecific symptoms. Due to its elusive nature, clinicians may overlook the diagnosis without a heightened level of suspicion. Common clinical symptoms: fever, sore throat, skin rash, lymphadenopathy, myalgia/arthralgia, diarrhea, weight loss, night sweats, headaches. Opportunistic infections occur with CD4 counts < 200 cells/microL. We will be discussing Cryptococcus.

CASE INFORMATION:

HPI: A 27 y.o. Male with no past medical history comes to the emergency department with a chief complaint of headache and abdominal pain. Pt states that the pain and headache began about 3 weeks ago and has been worsening.

The headache is diffuse but worse in the back of the head. Pt admits to feeling worse at night, having night sweats, subjective fevers, N/V, weight loss and decreased appetite. Pt denies photosensitivity, chest pain, dyspnea, and body aches.

Social: Pt denies IVDU, endorses heavy drinking, THC use, currently engaged in MSM.

PE: Ill-appearing, occipital tenderness to palpation, no nuchal rigidity, diffuse maculopapular rash across the forehead.

Labs: WBC 3.7-5.1; AST 38; ALT 65; UA neg; UDS THC and Opioids; HCVAB +; HIV screening +; HIV RNA PCR = 108k copies; CD4 = 33.

CSF: Cryptococcal anti-gen+ (1:2560) titer; Clear, Colorless; WBC 239/cc (ref 0-5); Lymphocytes 97% (ref 20-50%); RBC 3653/cc (ref 0-5); Glucose: 42 (ref 40-70); Protein: 42.9 (15-45); OP: 57 cm H20 (very high)

Imaging: CT Chest showing a single LUL Cavitary lung lesion

Assessment: Cryptococcal Meningitis Opportunistic Infection 2/2 HIV/AIDS

Treatment: Amphotecirin B (3 to 4 mg/kg IV per day); Flucytosine (100mg/kg q6h). Regimen recommended for minimum of 2 wks – may extend to 4-6 wks

RESULTS: After nine days of hospitalization, the patient disclosed a history of engaging in HIV high-risk behaviors and activities. This revelation prompted medical attention towards HIV testing and further evaluation. However, challenges arose during attempts to perform bedside lumbar puncture, leading to the decision to obtain the procedure through Interventional Radiology (IR). Following the diagnostic procedures, including HIV testing and assessment of CD4 counts, opportunistic bacterial tests were ordered to address potential complications. Subsequently, appropriate treatment was administered based on the test results, ensuring comprehensive care for the patient's condition.

CONCLUSIONS: Physicians should have a low threshold for suspicion for HIV. Give priority to early detection and proactive management to enhance patient outcomes. The absence of a history of risky behavior or activities should not deter a physician from pursuing an HIV diagnosis. An effective way to gather HIV-related risk factors is by obtaining the patient's history in a one-on-one setting. The lack of HIV testing resulted in complications and prolonged hospitalization, ultimately leading to the patient's death secondary to seizures and respiratory failure.

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