Case Presentation: A 27-year-old African American male with past medical history of hypertension presented with vomiting, diarrhea, chest pain and shortness of breath for about 1 week. He was septic with a temperature of 100.4F and heart rate of 130 bpm, but normotensive. No peripheral edema was present on exam. Leukocytosis (11.2K), anion gap metabolic acidosis (Gap 23, bicarbonate 7) and acute renal failure (creatinine 20.47; BUN 161) were present. UA showed proteinuria and microalbumin / creatinine ratio was 8,153. A Bicarbonate drip and emergent dialysis were started. Blood cultures grew Neisseria gonorrhea for which he received a course of IV ceftriaxone. RPR was positive, requiring treatment for late-latent syphilis. HIV screen was positive along with CD4 count of 23 and viral load of 323,493 copies. He was started on HAART with darunavir/cobicistat/emtricitabine/tenofovir alafenamide and Bactrim prophylaxis. Hospital course was complicated by hematochezia and CMV viremia (PCR 14,437 copies). Treatment with post-dialysis IV ganciclovir for 3-week was completed for CMV colitis/viremia. CMV retinitis was ruled out with fundoscopy, by Ophthalmology.
Discussion: This is a classic presentation for HIV associated nephropathy (HIVAN), a rapidly progressive decline in renal function with significant proteinuria and no peripheral edema. Although HIV is most often associated with opportunistic infections, it can cause a variety of complications in almost any organ. The kidney is commonly affected, with HIVAN being an important cause of rapidly progressive renal failure [1]. 90% of HIVAN patients are African American with 70% of those being males [2] with low CD4 counts and high viral loads. The risk of HIVAN increases with decreasing CD4 counts, increasing viral loads, and genetic factors [2]. Mortality is 2.5-3 times higher in ESRD patients with than those without HIVAN [2]. Histologically, HIVAN is a podocytopathy with active tubulointerstitial inflammation and collapsing glomerulopathy [4]. Therapy consists of early initiation of ART which has shown 57% reduction in mortality [5], and significant improvement in renal survival (adjusted hazard ratio 0.3) [6]. Adjunctive therapies include corticosteroids and RAAS blockade [2].
Conclusions: Although renal disease is common in HIV patients, initial presentations of HIV with rapidly progressive renal disease are atypical. Hospital Medicine physicians must include HIV in the differential diagnosis of rapidly progressive renal disease regardless of risk factors.