Case Presentation: A 21-year-old man with no previous medical history presented to the emergency department with nausea, vomiting and diarrhea for one week. Labs were significant for white blood cell (WBC) count 3.4 k/ul with decreased lymphocytes along with mild elevation of transaminases and lipase. He was thought to have viral gastroenteritis and was discharged. HIV labs were sent, which returned positive.Three days later, he returned with worsening nausea, vomiting, and now with visual hallucinations and altered mental status. CT head was unremarkable. He was admitted to the ICU. Labs revealed down trending WBC 1.9 k/ul (lymphocyte 0.7 k/ul) and platelets, worsening transaminases, elevated Alkaline phosphatase, INR and conjugated bilirubin. Imaging of the liver and spleen as well as all toxic and infectious work up including CSF analysis was unremarkable. CD4 count was 47, HIV viral load was 2,114,955 copies. He had an episode of seizures and developed rhabdomyolysis, along with renal failure leading to dialysis. Imaging of the brain and heart were unremarkable, including no abnormalities seen on EEG.Ferritin greater than 30,000 raised concern for hemophagocytic lymphohistiocytosis (HLH), however after initiating Anti-retroviral therapy (ART), ferritin trended down, making HLH unlikely. Patients’ liver and kidney function improved, dialysis was discontinued. Viral load was repeated and had down trended to 141 copies, CD4 count improved to 126. His mental status improved and he was transferred out of the ICU.
Discussion: As per the latest data available, 37.9 million people are affected globally with HIV. Acute HIV infection typically presents as a mononucleosis-type syndrome, though as many as 10-60% of patients are asymptomatic. HIV-associated multi-organ failure is a very rare diagnosis which, if missed, can cause serious consequences. Our patient presented with acute liver failure, encephalopathy with seizures, septic shock, acute renal failure requiring hemodialysis, and profound leukopenia. The mechanism for the multi-organ failure is not well understood, however the literature does reveal one other similar case by Tattevin et al. in which the patient also improved with immediate ART treatment. Although starting patients on ART during an acute infection remains controversial, these cases reveal that starting ART in patients presenting with life-threatening manifestations may be beneficial for the patient and may help improve symptoms if all other causes have been ruled out.
Conclusions: As physicians, we should be aware of multi-organ failure being a part of acute HIV infection and should maintain a high suspicion for it in patients who present with an unknown cause of sepsis and shock. If the patient is found to be HIV positive, they should be started on ART as early as possible which, as shown in our case, may rapidly decrease both morbidity and mortality.