Case Presentation: A 26-year-old male without past medical history presents with complaints of dark brown urine and diffuse muscle pain for the past 24 hours. He was noted to have a creatine phosphokinase was noted to be >100,000 units/L. He denied any preceding symptoms including mononucleosis-like symptoms, no heavy exercise, traumatic injury, or travel. He uses no prescription, over-the-counter, herbal supplement, tobacco, alcohol, or illicit drug use.Social history was significant for sexual intercourse with 14 male partners over the past year, with intermittent condom use, many of whom were positive for HIV. He has several tattoos which were not professionally performed. No history of hepatitis, blood transfusions or intravenous drug use. Acute hepatitis panel, HIV antibody, and anti-nuclear antibody was negative at the outside hospital. He was started on aggressive intravenous fluid resuscitation at without significant improvement of his creatine phosphokinase levels in the first few days. During his hospital stay, he developed intermittent fevers (Tmax 102.3°F), chills, and continued myalgias during his hospitalization. He had generalized lymphadenopathy on examination. A repeat HIV antibody test was positive with viral load showed 10 million copies of HIV virus and absolute CD4 count with 265 cells. Computed tomography of the abdomen and pelvis was unremarkable. Right upper quadrant ultrasound showed 3 benign hemangiomas. He was ultimately started on Biktarvy (bictegravir, emtricitabine, and tenofovir alafenamide) with viral suppression and rise in CD4 count.

Discussion: Acute human immunodeficiency virus (HIV) infection is defined by a negative HIV antibody test, with a concomitant elevated viral RNA level. Acute HIV infection usually causes a constellation of non-specific findings such as headache, nausea, fever, rash, pharyngitis, arthralgia, vomiting, myalgia and lymphadenopathy, however only a few select cases will present with rhabdomyolysis as the initial presentation of acute HIV. Rhabdomyolysis rarely occurs without other confounding variables such as viral, bacterial or fungal infection, initiation of antiretroviral medications, intravenous drug abuse, or alcohol abuse which are all known precipitants. A retrospective study performed by Koubar et al. analyzed a HIV Clinical registry with 7079 patients with 362 identified as having rhabdomyolysis each with a confounding cause for rhabdomyolysis beyond isolated HIV infection. Unfortunately, regardless of the cause of “rhabdomyolysis in the HIV population, this resulted in a 1.5-4 fold increase in the rate of death compared to the general population”.

Conclusions: Due to the severe morbidity and mortality associated with rhabdomyolysis (severe electrolyte imbalance, acute renal failure) in the HIV population, prompt recognition is important to expedite and initiate treatment. Though rare, rhabdomyolysis in an otherwise healthy individual with high risk sexual behaviors may warrant further investigation of acute HIV infection as the cause of their rhabdomyolysis.